[Senate Report 108-411]
[From the U.S. Government Publishing Office]



                                                       Calendar No. 802
108th Congress                                                   Report
                                 SENATE
 2d Session                                                     108-411

======================================================================



 
 A BILL TO AMEND THE INDIAN HEALTH CARE IMPROVEMENT ACT TO REVISE AND 
                            EXTEND THAT ACT

                                _______
                                

               November 16, 2004.--Ordered to be printed

                                _______
                                

   Mr. Campbell, from the Committee on Indian Affairs, submitted the 
                               following

                              R E P O R T

                         [To accompany S. 556]

    The Committee on Indian Affairs, to which was referred the 
bill (S. 556) to amend the Indian Health Care Improvement Act 
to revise and extend that Act; having considered the same, 
reports favorably thereon with an amendment in the nature of a 
substitute and recommends that the bill as amended do pass.

                                Purpose

    The purpose of the Indian Health Care Improvement Act 
Amendments of 2004 (S. 556) is to reauthorize the Act and 
provide a series of improvements to the Indian health care 
delivery system. The reauthorization is intended to raise the 
health status of American Indians and Alaska Natives to the 
highest possible level in accordance with Healthy People 
2010.\1\
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    \1\ ``Healthy People 2010 is the prevention agenda for the Nation. 
It is a statement of national health objectives designed to identify 
the most significant preventable threats to health and to establish 
national goals to reduce those threats.'' U.S. Department of Health and 
Human Services. www.healthypeople.gov. (last reviewed July 15, 2004).
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    S. 556 sets forth policies, programs and procedures 
designed to address health care deficiencies in native and 
urban Indian communities and streamline service delivery to 
those communities. In addition, S. 556 addresses the health 
problems and associated socio-economic conditions in native 
communities by authorizing the Indian Health Service (IHS) and 
tribes to adopt current health industry ``best practices''.

                               Background

    First enacted in 1976, the Act established the first 
comprehensive framework for the delivery of health care 
services for native people and authorized funding for health 
programs, projects, and facilities. The Act was last 
reauthorized in 1992.

History of Federal responsibility for Indian health care

    The history of the Federal responsibility for Indian health 
care is quite extensive and well-documented in numerous 
sources, including past Senate Reports on prior amendments to 
the Act. See eg., S. Rpt. 102-392. Nevertheless, an abbreviated 
history is appropriate to inform the need for reauthorizing the 
Act and specific provisions in S. 556.
    Based on the U.S. Constitution, treaties, statutes and the 
historical, political and legal relationship with the Indian 
tribes, the United States has assumed responsibility for the 
provision of health care to Indian people. This jurisprudence 
also serves as the backdrop for the government-to-government 
relationship.
    Extensive research indicates that the health of Indians\2\ 
deteriorated after the contact with the European colonists as 
the aboriginal inhabitants had no natural immunities to the 
diseases carried by the new arrivals. Decades later, when 
Federal policy forced the Indians to relocate to reservations 
and, in many cases, prohibited traditional practices--including 
traditional healing--the health of Indians continued to 
plummet. Thus, health care became a particularly significant 
element of the treaties and other agreements between the Indian 
tribes and the United States.
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    \2\ As the term is used in this Report, ``Indians'' includes 
American Indians and Alaska natives.
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    A. Agency Administration. Initially during the early 1800s, 
the health care provided was little more thanvaccinations for 
the Indians around the military posts to protect the soldiers and non-
Indians from the possibility that Indians might spread diseases. During 
the late 1800s, physicians and hospitals were added to the reservations 
and other outposts.
    According to the Task Force on Indian Health (Task Force 
Six) in the Final Report to the American Indian Policy Review 
Commission (Final Report), ``[t]he health care which Indians 
actually received in the first 100 years was delivered in a 
piecemeal, inconsistent fashion and the few appropriations made 
were never large enough to meet the overwhelming need.'' Final 
Report at 27.
    This lack of focus and priority was compounded by an ever-
shifting administration of Indian health among the different 
Federal agencies. The responsibility for Indian health first 
fell to the War Department in 1803, then to the Interior 
Department in 1849, before finally being transferred to the 
Department of Health, Education and Welfare (DHEW), the 
predecessor of the DHHS, in 1955. The Division of Indian Health 
within DHEW had initial responsibility for Indian health before 
eventually being renamed the Indian Health Service. Id. at 32.
    B. Congressional Action. In 1921, Congress enacted the 
Snyder Act, 25 U.S.C. 13, to provide for permanent 
appropriations authority for Indian health programs and 
services. However, the Snyder Act did not provide meaningful 
standards by which to measure progress in Indian health status 
or other improvements in services.
    Shortly after the responsibility for Indian health was 
transferred to DHEW, Congress passed the Indian Sanitation 
Facilities and Services Act, 42 U.S.C. 2004, which authorized 
the IHS to provide sanitation facilities to Indian communities. 
These sanitation facilities were critical to eliminating many 
health maladies associated with the lack of proper sanitation, 
such as dysentery and infectious hepatitis.
    The lack of standards in the Snyder Act and other organized 
efforts led Task Force Six to conclude in 1976 that ``there 
[was] no clear overall direction or policy for implementation 
of the various programs. As a result, the Indian Health 
Services operates primarily an emergency and crisis oriented 
service. * * * This has resulted in increased prevalence of 
certain health deficiencies which are virtually unknown in the 
general population.'' Final Report at 27.
    C. The Indian Health Care Improvement Act. Congress sought 
to end the piecemeal approach to Indian health and to provide 
meaningful direction with passage of the Act in 1976. The Act 
has been revised and extended three times since then, each time 
providing for additional advancements to raise the status of 
Indian health.
    Specific Provisions. Several important provisions were 
included as part of the comprehensive framework for improving 
Indian health. First, manpower training, recruitment and 
retention programs were established to increase the number of 
health professionals, especially Indians, in the Indian health 
care system. 25 U.S.C. 1612.
    Urban Indian Programs. In addition, the Act recognized the 
need for urban Indian health programs, with many Indians 
located in urban centers because of the Federal relocation 
policy pursued in the first half of the 20th Century. Many 
disparities urban Indians face can be attributed to that 
Federal policy. See Final Report at 142-145.
    Congress acknowledged that the Federal obligation for 
Indian health care did not end at the border of the 
reservation--even though relocation was initially to end 
services to these urban Indians\3\ rather than to improve the 
status of Indians (health, economic) in a meaningful way.\4\ 
See also S. Rpt. 100-508 at 25.
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    \3\ Relocating Indians from reservations to urban areas is an old 
Federal policy and program first begun in 1931. ``Relocation 
complemented other termination programs designed to promote rapid 
assimilation. Once relocated, Indians were cut off from the special 
federal services that had been available to them as reservation 
residents.'' Id.
    \4\ The Snyder Act, 25 U.S.C. 13, authorizes funding for health 
care for ``the Indians throughout the United States''. This statute 
neither confined the services to individuals who were members of 
federally-recognized tribes nor to those living only on reservations. 
The Snyder Act has never been repealed or otherwise limited in this 
respect.
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    Congress specifically included urban Indians as part of the 
Indian health care system in the Act in 1976 to correct these 
disparities first as pilot programs and then ``as a permanent 
part'' of the Indian health care system in 1988. S. Rpt. 100-
508, at 24. Congress has expanded health services to urban 
Indians since 1976. See Pub. L. 100-713, 101-630, and 102-573.
    Providing for urban Indian health has been a part of 
Federal policy for more than 30 years. The definition of 
``urban Indian'' remains the same in S. 556 as in current law 
and is well within the scope of Congressional authority to 
establish such definition.
    This definition does not create unlawful racial 
classifications simply because ``urban Indians'' include 
individuals who are members of a federally-recognized Indian 
tribe and, in some cases, individuals who are not enrolled 
members of any federally-recognized Indian tribe.
    The view that only members of federally-recognized tribes 
are eligible for such services has been thoroughly disavowed by 
Congress and the courts. First, Congress has very broad powers 
``to define who are Indians'' through its power to regulate 
commerce with Indian tribes.\5\ Second, Congress has defined 
``Indians'' in different ways under various statutes for 
different purposes. See e.g., Indian Arts and Crafts Act, Pub. 
L. 101-644, 25 U.S.C. 305; and No Child Left Behind Act, Pub. 
L. 107-110, 20 U.S.C. 7491; and the American Indian Probate 
Reform Act of 2004, Pub. L. 108-374, signed into law on October 
27, 2004.
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    \5\ U.S. Const., Art. I Sec. 8, cl. 3. See also Cohen, Felix. 
Handbook of Federal Indian Law, at 23. 1982 ed.; U.S. v. Holliday, 70 
U.S. 407, 417 (1865) (The broad power also includes Congress; dealings 
with individual Indians).
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    One such definition found in the Indian Reorganization Act 
of 1934, 25 U.S.C. 477, did not include the requirement of 
membership in any tribe and was upheld in U.S. v. John, 437 
U.S. 634 (1978). Courts have upheld the broad Congressional 
power in other contexts as well. Most recently, the court in 
U.S. v. Drewry, 365 F.3d 957, 961 (10th Cir. 2004) held that 
``enrollment in a tribe is not the only way an individual can 
show she is an Indian'' for Federal criminal jurisdictional 
purposes. The Drewry court cited a litany of cases which also 
support the principle that ``Indianness'' is not limited to 
membership in a federally-recognized tribe. See e.g., U.S. v. 
Antelope, 430 U.S. 641 (1997).
    Certainly the courts have not held that the breadth of 
Congressional power in Indian affairs is expansive only when 
legislating to the detriment of Indians. To the contrary, 
Courts have long held with great favor that Congress has the 
broad power to legislate for the benefit of Indians and to 
define who is an Indian.
    The history, policy and status of Indian health provide 
ample support for continuing and improving programs to urban 
Indians and, therefore, the Committee stands firm on not 
retreating from current law; and remains committed to improving 
the health care of urban Indians in this legislation.

Indian health status

    A. Health Status. The health status of Native Americans has 
improved significantly since the enactment of the Act in 1976, 
but the statistics remain grim. The goal of the Act was to 
raise the health status of Indians to achieve parity with that 
of other U.S. populations. With the basic goal still 
unrealized, the need for reauthorization grows even greater.
    Health Indicator Rates. Indians rank at or near the bottom 
of nearly every health and social indicator when compared to 
the general U.S. population. Health studies indicate 
disproportionately higher mortality rates for alcoholism 
(between 670-770%), tuberculosis (650%), diabetes (between 318-
420%), accidental injuries (280%), suicide (190%), and homicide 
(210%) than other populations. In addition to these specific 
health disparities, native people suffer from high rates of 
unemployment and poverty, live in substandard housing, and 
receive an inadequate education\6\--all of which contribute to 
poor health.
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    \6\ U.S. Department of Health and Human Services, Indian Health 
Service, Facts on Indian Health Disparities, 2002.
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    Alcohol and Substance Abuse. Native communities are 
increasingly plagued by mental health problems, including those 
exacerbated by the use of alcohol and substances, at staggering 
rates which destroy native families. Federal programs currently 
offer several disparate and uncoordinated mental health, and 
alcohol and substance abuse prevention and treatment programs. 
Better coordination of these programs within a comprehensive 
behavioral health program will not only bring greater benefits 
to native people, but will make a more efficient and effective 
use of scarce resources.
    Prevention. Long-term prevention efforts would also 
significantly improve the health status of Indians. Many 
programs have focused on treatment due, in part, to the 
progressive, degenerative or advanced nature of the diseases. 
However, many of the diseases which plague native communities 
are preventable, such as diabetes, and their prevention would 
reduce the long-term costs to the health care system. More 
attention is needed to programs focusing on health promotion 
and disease control and prevention.
    B. Health Care System. Since the Act was first passed, the 
Indian health care system has undergone significant changes, 
particularly in the tribal administration of services. Through 
the Act, combined with the passage of the Indian Self-
Determination and Education Assistance Act (ISDEAA) in 1975, 25 
U.S.C. 450, et seq., Indian tribes gained the means to 
administer Indian health programs.\7\
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    \7\ In FY 2005, the IHS projects that ``approximately $947 million 
of program and tribal shares finds will be transferred to support 87 
compacts.'' Department of Health and Human Services, Fiscal Year 2005, 
Indian Health Service, Justification of Estimates for Appropriations 
Committee (Justification) at 129.
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    However, that means is sometimes thwarted by cumbersome 
bureaucracy and narrow interpretations of the ISDEAA. The 
ISDEAA authorizes Indian tribes or tribal organizations to 
administer programs previously operated by the IHS.
    Tribal Administration. As part of that administration, 
Indian tribes or tribal organizations enter contracts or 
compacts with the IHS through which they may also incorporate 
grants or redesign programs. 25 U.S.C. 450f and 458aaa-4. 
Administering such contracts allows the tribal contractors to 
save significant administrative costs and increase services to 
tribal members.\8\
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    \8\ Tribal Perspectives on Indian Self-Determination and Self-
Governance in Health Care Management, National Indian Health Board, 
Vol. II at 32.
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    The Committee has received testimony regarding the need to 
clarify that this funding transfer mechanism for Indian health 
programs is available for grants under the Act as well. 
However, the Committee does not intend to diminish the 
Secretary's discretion to award grants under the Act.
    The Committee also intends that those programs that were 
grants in current law (i.e., the Act as passed in 1992) remain 
as grants, unless the Secretary determines they are 
appropriate, contractible functions. However, nothing in S. 556 
is intended to modify in any way the Indian tribes authority 
under ISDEAA to incorporate a grant after it has been awarded 
in an ISDEAA Title I or Title V agreement.
    Flexibility is a hallmark in the delivery of Indian health 
care, for both the DHHS and Indian tribes. In S. 556, the 
Committee included the definition of ``fund'' and ``funding 
agreement'' to make clear that the funding mechanisms available 
for Indian health programs include a wide range of options, 
such as contracts or compacts under the ISDEAA as well as 
grants.
    The ISDEAA refers to ``annual funding agreements'' and 
``funding agreements'' under Titles I (25 U.S.C. 450) and V (25 
U.S.C. 458aaa), respectively, and those terms are both 
contemplated within the Act's definition of 
``fundingagreement'' to complement, not conflict with, each other. The 
Committee encourages the use of contracts and compacts to enable tribal 
contractors to save costs, but recognizes that certain grant 
requirements or conditions may still be appropriate and incorporated 
into those legal agreements. The Committee believes that these 
principles will improve the administration of Indian health.
    Services. According to the IHS, the Indian health programs 
are administered by the IHS directly, Indian tribes, tribal 
organizations and urban Indian organizations, serving over 1.6 
million Indians. Justification at 15.
    According to the IHS, ``there are 594 direct health care 
facilities, including 51 hospitals, 231 health centers, 5 
school health centers, and 309 health stations, satellite 
clinics and Alaska village clinics.'' Justification at 15.
    The services include inpatient and ambulatory care with an 
increased focus on preventive care. More specialized care may 
be provided through contract health services wherein the IHS 
contracts with non-IHS providers for these services.
    Community Health Aide Program. The Community Health Aides/
Practitioner Program (CHAP) was established several years ago 
under the authority of the Snyder Act to address the severe 
shortage of health professionals in Alaska. The program has 
operated with much success and has received substantial support 
from the Administration. The success of the CHAP has led the 
Committee to authorize the development of a national CHAP.
    Based on the success of the medical component of the CHAP, 
a dental component has been developed to address the oral 
health crisis in Alaska. The Committee is aware that several 
practitioners are currently in a 2-year training program for 
certain dental procedures. Once they complete their training, 
they will be under supervision of a licensed dentist until they 
have been certified to provide certain dental procedures.
    However, the American Dental Association (ADA) expressed 
concerns regarding the training of the CHAPs in providing so-
called ``irreversible procedures'' for Indians.
    The Committee recognizes there should be a balance of 
quality care and access to care in developing these programs. 
Arguably, without such programs, many Alaska natives will have 
no dental care whatsoever.
    The Committee also recognizes that developing a dental 
volunteer program as the ADA has suggested to the Committee may 
provide temporary relief to the crisis, but may not be 
sufficient to address the real need or have funding available 
even for a ``volunteer'' program. The Committee also 
understands that the IHS's dental priority in the Indian 
communities located in the lower 48 states is to fill vacancies 
with dentists and the national CHAPs program is not slated to 
begin in the near future.
    Therefore, the Committee strongly encourages the 
Administration, the Indian tribes and the ADA to work together 
to address the need and fill the vacancies within the Indian 
health care system.
    Elevation. While Indian health care has received increased 
attention by the Administration by accentuating the role of the 
Director of IHS among other things--institutionalizing that 
role is important. Bringing a heightened role to the IHS is 
needed to improve advocacy efforts for Indian health care and 
coordination with other agencies in improving the health status 
of Indians. Accordingly, S. 556 includes a provision to elevate 
the position of Director to that of Assistant Secretary--Indian 
Health.
    Funding. Funding is one area where additional advocacy 
could assist. Indian health has received incremental increases 
in funding over time. According to the U.S. Commission on Civil 
Rights, the funding has grown from $24.5 million in 1955 to 
$3.5 billion in 2004. See U.S. Commission on Civil Rights, A 
Quiet Crisis: Federal Funding and Unmet Needs in Indian Country 
(2003) at 40. Yet, according to some estimates, the actual need 
approaches $10 billion per year over the next 10 years, with 
``a one-time appropriation of $8 billion for facility 
construction * * *.'' Id. at 49.
    Third Party Reimbursements. The ability of IHS, Indian 
tribes, tribal and urban Indian organizations to access third 
party reimbursements, such as Medicaid, becomes even more 
important. Several Indian-specific provisions had been included 
in the Medicare Prescription Drug and Modernization Act of 
2003, Pub. L. 108-173, and, therefore, additional amendments 
recommended by the National Steering Committee (NSC), which was 
constituted to facilitate reauthorization, were not included in 
the reported bill.
    However, the decision not to include those provisions in 
this legislation should not be viewed as a rejection of them on 
the merits. The Committee expects that these Indian-specific 
provisions for Medicare will be considered when future 
amendments are considered to Medicare.
    Payment systems have been the subject of much debate during 
the development of this legislation. The study on the extent 
Social Security Act payment methodologies take into account the 
unique circumstances of Indian health services was not included 
in the reported bill. The DHHS indicated to the Committee that 
it has sufficient authority under existing law to undertake 
this payment methodology review.
    Thus, the Committee is confident the Secretary will perform 
such a review pursuant to existing authority. The Committee 
encourages the Secretary consider current payment methodologies 
applicable to the Indian health system with the objective of 
balancing access to care and payment at rates consistent with 
those for most favored providers.
    The Committee is aware that the costs of changing to a 
different payment methodology could cost the IHS and Indian 
tribes up to $16 million. Therefore, in the interim, the 
Committee expects the Secretary to maintain the current payrate 
unless another rate is determined by the Secretary to be more 
beneficial to Indian health programs, given the additional costs 
associated with the new system.
    The Committee is aware that Indian tribes have sought to 
interface with Medicaid managed care organizations (MCO) or to 
develop their own tribal MCO. The primary goals for 
participation are to ensure the appropriate entities achieve 
the full benefit of the Medicaid funding, particularly the 
capitated payments, and increase access for Indians to these 
programs.
    First, when an Indian--enrolled in a MCO authorized by a 
State Medicaid Plan--receives covered health services from an 
Indian health program, the MCO should reimburse the Indian 
health program appropriately.
    The rate should be no less than the rate of reimbursement 
for preferred providers or at such other rate that may be 
negotiated between the MCO and the Indian health program. In 
the alternative, the State Medicaid Plan may make the 
appropriate payments to the Indian health program, and then 
make an adjustment in the capitation payment to the MCO.
    The Committee is aware that Medicaid Indian patients may be 
enrolled in Medicaid MCOs for which the State Medicaid Plan 
makes capitation payments to the MCO. Often such an Indian 
enrollee will use the Indian health program for needed health 
care, especially when the MCO network providers are distant 
from or unfamiliar to the patient.
    Having received a capitation payment from the Medicaid 
Plan, the MCO should not be permitted to escape responsibility 
for reimbursing the Indian health provider when the MCO has not 
included the Indian health program in its provider network, yet 
has received Medicaid funding as a result of that Indian's 
enrollment in the Plan.
    The Committee is aware that some Indian health programs 
have attempted to join the network, but have been met with some 
resistance or, in the end, have found it not feasible to join. 
The Committee believes the Indian health programs should not be 
treated disparately in payment. Thus, S. 556 fosters 
cooperative efforts in increasing access and payment equity.
    Streamlined Bureaucracy. In addition to these third party 
reimbursements, streamlining bureaucracy--which provides 
residual increases to the aggregate health care funding--is 
also needed.
    Program Administration. Throughout S. 556, the Committee 
has identified many priorities and programs upon which the IHS 
and tribes should focus. The Committee also believes that 
flexibility in program administration is needed to improve the 
health status of Indian people and is best achieved by allowing 
Indian tribes and the IHS to determine these matters at the 
local level.
    Such determinations may be made through a variety of tools 
available to the IHS and Indian tribes such as consultation and 
negotiated rule-making. The Committee particularly favors 
negotiated rule-making, pursuant to 5 U.S.C. 561, et seq., in 
developing the various program elements for several reasons.
    First, the Indian tribal and urban health providers--as 
first responders in the health system--should have direct 
involvement in developing these programs and the regulations 
that govern those programs. Second, tribal involvement leads to 
a more informed rule and fosters tribal support.
    Finally, negotiated rule-making saves costs to all parties 
in the long run. By building a higher level of consensus in the 
regulations, the IHS lowers the potential for legal challenges 
to the rules and associated litigation costs. The Committee 
favors the consensus-building procedure over litigation and has 
found it to be useful in other initiatives such as education, 
housing and self-governance.\9\
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    \9\ See e.g., No Child Left Behind Act, Pub. L. 107-110, 25 U.S.C. 
2001, et seq.; Native American Housing Assistance and Self-
Determination Act, Pub. L. 104-330, 25 U.S.C. 4116; Indian Self-
Determination and Education Assistance Act, Pub. L. 106-477, 25 U.S.C. 
458aa-16.
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    The Committee recognizes that the Administration has 
renewed efforts to involve Indian tribes in decision-making, 
but the Committee remains committed to promoting tribal input 
by institutionalizing such efforts.

National Steering Committee

    In June, 1999, the Director of the IHS convened the NSC 
comprised of tribal leaders and representatives from Indian 
health organizations to consult on the reauthorization. The NSC 
held a series of meetings in 1999 during which extensive 
discussions were held between the NSC and DHHS officials.
    In the meantime, the tribal officials of the NSC set out to 
craft a comprehensive reauthorization. During the drafting of 
this legislation, the tribal officials obtained technical 
assistance from various DHHS officials.
    The draft document produced served as the basis for 
predecessor bills S. 2526 (106th Congress) and S. 212 (107th 
Congress). Neither bill was enacted, but S. 212 did receive 
significant attention from the Administration.
    By letter dated September 27, 2001, the Administration 
provided its views on S. 212 to the Committee. During 2002, 
tribal officials and Committee staff reconvened to address the 
Administration's concerns. The entire set of proposals was not 
finalized in time to be incorporated into S. 556 upon 
introduction.
    But due to the size and importance of the legislation, the 
Committee was compelled to begin addressing the issues 
surrounding the reauthorization. The proposed revisions were 
completed in May, 2003, and have been largely incorporated into 
the substitute amendment to S. 556 which was favorably reported 
by the Committee.

Prior legislative activity

    The reauthorization of the IHCIA has been a work in 
progress since the 106th Congress when Senator Campbell 
introduced S. 2526, the Indian Health Care Improvement Act 
Reauthorization of 2000 for himself and for Senators Inouye and 
McCain. S. 2526 was favorably reported by the Committee to the 
full Senate, but no further action was taken.
    During the 107th Congress, Senator Campbell introduced S. 
212, the Indian Health Care Improvement Act Reauthorization of 
2001, on January 30, 2001 for himself and for Senators Inouye 
and McCain. The bill was co-sponsored by Senators Johnson, 
Dorgan, Daschle, Feinstein, and Murray.
    The bill was referred to the Committee, but not reported 
out.

                      Summary of Major Provisions


                    TITLE I. INDIAN HEALTH MANPOWER

    The purpose of Title I is to increase, to the maximum 
extent feasible, the number of American Indians and Alaska 
Natives entering the health professions and to ensure an 
adequate supply of health professionals to the IHS, tribal and 
urban Indian health programs.
    This title covers recruitment, scholarships, extern 
programs, continuing education, community health 
representatives, loan repayment, advanced training and 
research, nursing, tribal cultural and history, inmed, health 
training, incentives, residency and community health aides.

                       TITLE II. HEALTH SERVICES

    The purpose of Title II is to establish programs that 
respond to the health needs of Indians. This title has a 
specific diabetes provision which complements the Special 
Diabetes Program for Indians authorized pursuant to the 
Balanced Budget Act of 1997.
    It also governs the Indian Health Care Improvement Fund 
through which Appropriation Acts supply funds to eliminate 
health deficiencies and disparities in resources made available 
to Indian tribes and communities.
    This title also contains a catastrophic health emergency 
fund; health promotion and disease prevention services; hospice 
feasibility; research; mental health; managed care feasibility; 
Arizona, North Dakota, South Dakota, Trenton and California 
contract health services programs; mammography; patient travel; 
epidemiology; school health education; Indian youth; 
psychology; tuberculosis; environmental and nuclear health 
hazards, and women's health.

                         TITLE III. FACILITIES

    The purpose of Title III relates to the construction of 
health facilities, including hospitals, clinics, and health 
stations, necessary staff quarters, and of sanitation 
facilities for Indian communities and homes. It also would 
require the Government Accountability Office (GAO) to conduct a 
comprehensive needs report on Indian health needs for 
inpatient, outpatient and specialized care facilities. It also 
would require newly-constructed/renovated facilities, whenever 
practicable, to meet the construction standards of any 
nationally-recognized accrediting bodies.

                  TITLE IV. ACCESS TO HEALTH SERVICES

    The purpose of Title IV is to address payments to the IHS 
and tribes for services covered by the Social Security Act 
Health Care programs, and to enable Indian health programs to 
access reimbursements from third party collections.
    This title includes provisions to increase Indian 
enrollment and participation in the third party health 
services, including tribal outreach programs and advisory 
groups.

               TITLE V. HEALTH SERVICES FOR URBAN INDIANS

    The purpose of Title V is to establish programs in urban 
centers to make health services more accessible to Indians who 
live in urban areas. This title authorizes the Secretary to 
enter into contracts or grants to urban Indian organizations to 
administer health programs and sets forth basic requirements.
    This title also establishes the Office of Urban Indian 
Health to provide central oversight of the programs and 
services. Title V also extends Federal Tort Claims Act coverage 
to urban Indian organizations and provides access to the 
Federal sources of supply for pharmaceutical purchases.

                 TITLE VI. ORGANIZATIONAL IMPROVEMENTS

    Title VI changes the ``Director--IHS'' to the ``Assistant 
Secretary--Indian Health''. This title also authorizes the 
Secretary through the IHS to establish an automated management 
information system as well as other duties as assigned by the 
Secretary for the IHS.

                 TITLE VII. BEHAVIORAL HEALTH PROGRAMS

    Title VII is revised from current law (which only addresses 
substance abuse programs) to provide a comprehensive focus on 
behavioral health. It combines all substance abuse, mental 
health and social service programs in one title and integrates 
these programs to enhance their performance and efficiency.
    The IHS is to provide comprehensive alcohol and substance 
abuse prevention and treatment programs, rehabilitation and 
aftercare services, an IHS youth program, and training and 
community education. Demonstration projects are outlined as 
well as grants focusing on Fetal Alcohol Syndrome and Fetal 
Alcohol Effect. It also expands the authorization to establish 
inpatient mental health facilities in each IHS Area.
    The title also addresses the responsibilities of the IHS as 
outlined by the Memorandum of Agreement pursuant to section 402 
of the Indian Alcohol and Substance Abuse Prevention and 
Treatment Act of 1986. The IHS will determine the scope and 
need for substance abuse programs and estimate adequate 
funding.
    This title authorizes funding for development of innovative 
community-based behavioral health services, including child 
sexual abuse programs.

                       TITLE VIII. MISCELLANEOUS

    The purpose of Title VIII is to address miscellaneous 
topics including a compilation of the reports required under 
the Act. It also applies the Negotiated Rulemaking Act to 
various activities under the Act. Other provisions require the 
Secretary to develop a plan of implementation to submit to 
Congress. This title also describes the eligibility of 
California Indians for IHS services and authorizes a Commission 
to study the issue of Indian health funding as an entitlement.

                          Legislative History


Legislative activity

    During the 108th Congress, Senator Campbell introduced S. 
556, the Indian Health Care Improvement Act Reauthorization of 
2003, on March 6, 2003, for himself and for Senators Inouye and 
McCain. The bill was referred to the Committee on Indian 
Affairs which, as noted below, immediately began holding 
hearings to advance the legislation.
    On July 17, 2003, Senator Johnson was added as a cosponsor. 
Senator Murray was added as a cosponsor on June 3, 2004, and 
Senator Daschle was added as a cosponsor on June 24, 2004. 
Senator Bingaman was added as a cosponsor on September 23, 
2004. On September 24, 2004, Senator Dorgan was added as a 
cosponsor. Senator Murkowski was added as a cosponsor on 
October 10, 2004 and Senator Cantwell was added as a cosponsor 
on November 17, 2004.
    On the House side, Congressman Don Young introduced a 
companion bill, H.R. 2440, Indian Health Care Improvement Act 
Amendments of 2003 on June 11, 2003.

Hearings held during the 108th Congress

    The Committee held eight hearings overall since the 106th 
Congress on the reauthorization of the Act and four hearings 
during the 108th Congress.
    On April 2, 2003, the Committee held its first hearing in 
the 108th Congress to reauthorize the IHCIA, addressing the 
``One-HHS'' initiative and the need for reauthorization. The 
witnesses included DHHS and members of the NSC.
    On July 16, 2003, the Committee held the second hearing--
jointly with the House Resources Committee--which addressed 
health disparities, sanitation facilities and urban Indian 
clinics. Witnesses included representatives from the Department 
of Housing and Urban Development (DHUD), DHHS, the NSC, Alaska 
Native Tribal Health Consortium, Association of American Indian 
Physicians, and Urban Indian Health Clinics.
    On July 23, 2003, the Committee held the third hearing to 
receive testimony on Medicaid and Medicare issues from 
representatives from Indian tribes, tribal health clinics and 
Indian health consultants. The DHHS was invited, but provided 
no witness for the hearing.
    To complete the series of hearings and expedite the mark-up 
of this legislation, the DHHS was informally invited to testify 
on the Medicaid and Medicare issues for possible Fall, 2003 and 
Spring, 2004 hearings. However, the DHHS demurred.
    Finally, on July 21, 2004, Secretary Thompson testified 
before the Committee regarding the Administration's views on 
the proposed legislation. At this hearing, the Secretary 
expressed enthusiastic support of the reauthorization and his 
desire to see it enacted before the end of 2004.

            Committee Recommendation and Tabulation of Vote

    In an open business session on September 22, 2004, the 
Committee considered a substitute amendment proposed by Senator 
Campbell. By a unanimous vote, the Committee ordered the 
substitute amendment favorably reported to the full Senate with 
the recommendation that the bill do pass.

                      Section-by-Section Analysis

    Section 1. Short Title. Section 1 provides the short title 
of the act as the ``Indian Health Care Improvement Act 
Amendments of 2004''.
    Section 2. Indian Health Care Improvement Act Amended. 
Section 2 sets forth the provisions of the Act beginning with 
section 1 and ending with section 818. The following section 
numbers of this analysis reflect the section numbers of the 
Act.
    Section 1. Short Title; Table of Contents. Section 1 sets 
forth the short title and table of contents.
    Section 2. Findings. Section 2 sets out Congressional 
findings for the Act by providing a historical context for 
Federal-tribal relations; a context to the framework of Indian 
health; and a summary of the history, testimony, evidence, 
research and other information relevant to the development of 
the Indian health care system.
    Section 3. Declaration of National Indian Health Policy. 
This section declares the national policy to be the fulfillment 
of the special trust responsibility and legal obligation to 
Indians, and to continue to improve the health status of Indian 
people.
    Section 4. Definitions. Section 4 provides definitions for 
terms used throughout the Act. New definitions for the terms 
``Fund or funding'' and ``Funding Agreement'' were added to 
provide clarity and reflect current practice and administration 
of Indian health programs.
    The term ``health profession'' includes a wide variety of 
practices. The Committee provides the list as examples of the 
primary types of professions employed throughout the Indian 
health system. However, the Committee recognizes that the IHS, 
Indian tribes or urban Indian organizations may need 
flexibility in including an appropriate health profession to 
meet the local needs and based on availability of funding.

        TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT

    Section 101. Purpose. This section states the purpose of 
this title is to increase the number of Indians entering the 
health professions and to assure an optimum supply of health 
professionals to provide health services to Indians.
    Section 102. Health Professions Recruitment Program for 
Indians. Section 102 authorizes funding for recruitment 
programs to include such activities as identifying Indians with 
potential for entering health professions, publicizing funding 
sources, and establishing programs to facilitate enrollment in 
applicable courses of study.
    This section may also include appropriate intern or 
temporary employment programs during any nonacademic period of 
the year. However, these programs are not designed to be summer 
employment programs, but rather are to increase the stability 
of health professional employment. This section also addresses 
funding applications and amount of funding to be provided, as 
well as defining who is an Indian for purposes of sections 103 
and 104.
    Section 103. Health Professions Preparatory Scholarship 
Program for Indians. Section 103 authorizes scholarships to 
Indians for compensatory preprofessional education as well as 
pregraduate education leading to a baccalaureate degree in a 
preparatory field for a health profession.
    Section 103 also prohibits denial of a scholarship based 
solely on scholastic achievement if the applicant has already 
been admitted or maintains good standing at an accredited 
institution or if the applicant is eligible for assistance 
under another Federal program.
    Section 104. Indian Health Professions Scholarships. 
Section 104 authorizes scholarships to Indians who are enrolled 
full- or part-time in accredited schools pursuing courses of 
study in the health professions. Such scholarships are 
designated as Indian Health Scholarships. The section further 
sets forth how the funding for these scholarships is to be 
allocated and addresses all the requirements of the active duty 
service obligation incurred as a result of the scholarship, 
including breach of contract situations.
    Section 105. American Indians Into Psychology Program. This 
section authorizes grants to at least 3 colleges and 
universities for developing and maintaining Indian psychology 
career recruitment programs. The Quentin N. Burdick Program 
Grant at the University of North Dakota is authorized 
specifically. This section directs the Secretary to issue 
regulations for competitive funding, specifies conditions of 
the grants and active duty service requirements.
    Section 106. Funding for Tribes for Scholarship Programs. 
Section 106 authorizes the Secretary to make funds available to 
Tribal Health Programs for the purpose of educating Indians to 
serve as health professionals in Indian communities. The 
requirements for receiving such funds; the course of study; 
contract conditions; specific parameters for a breach of 
contract; the relationship of a scholarship under this section 
to the Social Security Act; and conditions of continuance of 
funding are all specified in this section.
    Section 107. Indian Health Service Extern Programs. Section 
107 gives preference for employment in the IHS, a Tribal Health 
Program, Urban Indian Organization or other agencies within the 
Department, to any recipient of a scholarship pursuant to 
section 104 or 106. The section specifies that such employment 
does not count toward any active duty service obligation. It 
specifies the timing and length of employment and exempts the 
program from any competitive personnel system or agency 
personnel limitation. The section further specifies that an 
individual employed under this section will receive practical 
experience in the health profession in which he or she is 
studying.
    Section 108. Continuing Education Allowances. This section 
authorizes the Secretary to provide allowances to health 
professionals employed in an Indian Health Program or an Urban 
Indian Organization to enable them to take leave of their duty 
stations for a period of time each year for professional 
consultation and training courses.
    Section 109. Community Health Representative Program. 
Section 109 authorizes the Community Health Representative 
Program for training and using Indians as community health 
representatives. The section specifies the duties of the IHS 
regarding this program, including providing a high standard of 
training for Community Health Representatives to ensure that 
these representatives provide quality health services to Indian 
communities.
    Section 110. Indian Health Service Loan Repayment Program. 
This section establishes the Indian Health Service Loan 
Repayment Program to ensure an adequate supply of trained 
health professionals to maintain accreditation of and provide 
health care services to Indians. The section specifies 
eligibility for the program; application information; 
priorities; recipient contracts; deadlines for decision on 
applications; a loan repayment program; a waiver from any 
employment ceiling; a recruitment program; non-applicability of 
section 214 of the Public Health Service Act; assignment of 
individuals; breach of contract; waiver or suspension of 
obligation; and requires an annual report to Congress under 
section 801.
    Section 111. Scholarship and Loan Repayment Recovery Fund. 
Section 111 establishes an Indian Health Scholarship and Loan 
Repayment Recovery Fund within the Treasury of the United 
States. The section specifies the use of these funds, the 
investment of the funds, and the sale of obligations by the 
Secretary of the Treasury. The Administration expressed 
concerns with investing appropriated funds as being 
inconsistent with standard Federal investment policy. 
Provisions were added to expressly exclude the investment of 
Federally-appropriate funds. However, other types of funds may 
still be invested as needed.
    Section 112. Recruitment Activities. Section 112 permits 
the Secretary to reimburse certain travel expenses to health 
professionals seeking positions with Indian Health Programs or 
Urban Indian Organizations. Unpaid volunteers, potential 
candidates for contracts under section 110, and their spouses 
are all eligible for such reimbursement of travel. In addition, 
this section requires the Secretary to assign one individual in 
each Area Office to have full-time responsibility for 
recruitment activities.
    Section 113. Indian Recruitment and Retention Program. 
Section 113 requires the Secretary to fund innovative 
demonstration projects to enable Tribal Health Programs and 
Urban Indian Organizations to recruit, place, and retain health 
professionals to meet their staffing needs. The section also 
specifies that any Tribal Health Program or Urban Indian 
Organization is eligible to apply for these funds.
    Section 114. Advanced Training and Research. This section 
establishes a demonstration project to enable certain health 
professionals to pursue advanced training or research area of 
study, where a need exists, for a substantial period of time. 
The section specifies a service obligation and equal 
opportunity for participating in the program.
    Section 115. Quentin N. Burdick American Indians Into 
Nursing Program. Section 115 authorizes the Quentin N. Burdick 
American Indians into Nursing Program for the purpose of 
increasing the number of nurses, nurse midwives, and nurse 
practitioners who deliver health care services to Indians. The 
section specifies potential grant recipients; how grants may be 
used; information which must be included in applications for 
the grant; preferences for grant recipients; establishment and 
maintenance of a program at the University of North Dakota; and 
an active duty service obligation.
    Section 116. Tribal Cultural Orientation. This section 
requires certain employees of the IHS who serve Indian Tribes 
in each Service Area to receive instruction in the history and 
culture of the tribe they serve. The section requires the 
Secretary to develop such a program in consultation with the 
affected Indian entity, to be implemented through tribal 
colleges or universities, include instruction in American 
Indian studies, and describe the use and place of Traditional 
Health Care Practices.
    Section 117. INMED Program. Section 117 authorizes the 
Secretary to provide grants to colleges and universities to 
maintain and expand the Indian health careers recruitment 
program (Indians Into Medicine Program). The Quentin N. Burdick 
Grant is one of the authorized grants. This section also 
specifies requirements for institutional applicants for these 
grants.
    Section 118. Health Training Programs of Community 
Colleges. This section requires the Secretary to award grants 
to accredited, accessible community colleges to assist in 
establishing health profession education leading to a degree or 
diploma for individuals who desire to practice such profession 
on or near a reservation or Indian Health Program. The 
Secretary is also required to award grants to accredited, 
accessible community colleges that already have these programs. 
The Secretary must provide technical assistance to encourage 
community colleges to establish and maintain such programs. 
Finally, any program receiving assistance under this section is 
required to provide advanced training for health professionals. 
Funding priorities are provided to tribal colleges and 
universities in Service Areas where they exist.
    Section 119. Retention Bonus. Section 119 permits the 
Secretary to provide retention bonuses to certain health 
professionals. Rates for retention bonuses and conditions for 
default of retention agreement are also specified.
    Section 120. Nursing Residency Program. This section 
establishes a program to enable Indians who are nurses working 
for an Indian Health Program or Urban Indian Organization to 
pursue advanced training. Eligibility, program parameters and 
service obligations are specified.
    Section 121. Community Health Aide Program for Alaska. 
Section 121 directs the Secretary to develop and operate the 
CHAP in Alaska. Requirements and criteria are specified for the 
Alaska program. In addition, the Secretary is authorized to 
develop and operate a similar program on a national basis 
without reducing funds for the Alaska program.
    Section 122. Tribal Health Program Administration. This 
section requires the Secretary to provide training for Indians 
in the administration and planning of Tribal Health Programs.
    Section 123. Health Professional Chronic Shortage 
Demonstration Programs. In this section the Secretary is 
authorized to fund demonstration programs for Tribal Health 
Programs to address the chronic shortages of health 
professionals. Each demonstration program shall incorporate a 
program advisory board composed of representatives from the 
tribes and Indian communities which are served by the program.
    The Indian tribes recommended automatic designation of 
shortage areas under 42 U.S.C. 250, et seq., upon request by 
the Indian tribes. The Committee has been made aware that 
tribal applications receive little or no attention and, 
therefore, Indian communities cannot receive the benefit of the 
designation.
    However, the Administration objected to the automatic 
designation and instead committed to working with the Indian 
tribes and the Health Resources and Services Administration to 
assist them in achieving such designation. The Committee is 
pleased with this commitment and will look forward to hearing 
the status of tribal applications in the future.
    Section 124. Treatment of Scholarships for Certain 
Purposes. Scholarships provided under this section are deemed 
``qualified Scholarships'' for purposes of section 11 of the 
Internal Revenue Code of 1986. Such designation means the 
scholarship funds are not considered taxable income of the 
recipient.
    Section 125. National Health Service Corps. This section 
prohibits the Secretary from removing a member of the National 
Health Service Corps from an Indian Health Program or Urban 
Indian Organization or withdraw funding to support such member 
unless the Secretary ensures that Indians will experience no 
reduction in health services. The section also exempts National 
Health Service Corps scholars qualifying for the Commissioned 
Corps in the United States Public Health Service from full-time 
equivalent limitations when serving as a Commissioned Corps 
officer in a Tribal Health Program or an Urban Indian 
Organization.
    Section 126. Substance Abuse Counselor Educational 
Curricula Demonstration Programs. Section 126 authorizes the 
Secretary to enter into contracts or make grants to accredited 
colleges and universities to establish demonstration programs 
developing curricula for substance abuse counseling. Duration 
and renewal of the grant is specified. The section also 
establishes the criteria for review and approval of the 
applications, requires the Secretary to provide technical and 
other assistance to grant recipients, requires the Secretary to 
submit an annual report to the President under section 801 and 
defines the term ``educational curriculum''.
    Section 127. Behavioral Health Training and Community 
Education Programs. This section requires the Secretary, with 
the Secretary of the Interior and in consultation with Indian 
Tribes and Tribal Organizations, to conduct a study and compile 
a list of certain types of staff positions within the Bureau of 
Indian Affairs, the IHS, Indian Tribes, Tribal Organizations 
and Urban Indian Organizations, which should include training 
in any aspect of mental illness, dysfunction, or self 
destructive behavior.
    The Secretary is then required to provide training criteria 
appropriate for each type of position and ensure that this 
training is provided. On request of the appropriate Indian 
entity, the Secretary is required to develop and implement a 
program of community education on mental illness, as well as 
technical assistance to tribal entities to develop community 
education materials.
    Within 90 days of enactment, the Secretary is required to 
develop a plan to increase behavioral health services by at 
least 500 staff positions within 5 years, with at least 200 of 
such positions devoted to child, adolescent, and family 
services.
    Section 128. Authorization of Appropriations. Section 129 
authorizes appropriations as are necessary to carry out this 
title for each fiscal year through 2015.

                       TITLE II--HEALTH SERVICES

    Section 201. Indian Health Care Improvement Fund. This 
section authorizes the use of funds for the purposes of 
eliminating the deficiencies in health status and resources for 
tribes; eliminating backlogs and meeting the needs in health 
care services; eliminating the inequities in funding for direct 
care and contract health service programs; and augmenting the 
ability of the IHS to meet its various responsibilities. 
Funding authorized by this section may not be used to offset 
appropriated funds and must be used to improve the health 
status and reduce the resource deficiencies of tribes.
    This section also provides definitions applicable to this 
section and requires that Tribal Health Programs be equally 
eligible for funds as the IHS. A report is required to be 
submitted to Congress 3 years after enactment which addresses 
the current health status and resource deficiency for each 
Service Unit. Funds appropriated under this section are to be 
included in the base budget of the Indian Health Service for 
determining appropriations in subsequent years.
    Finally, nothing in this section is intended to diminish 
the primary responsibility of the Indian Health Service to 
eliminate backlogs in unmet health care nor to discourage 
additional efforts of the IHS to achieve equity among tribes 
and tribal organizations.
    Section 202. Catastrophic Health Emergency Fund. Section 
202 establishes the Catastrophic Health Emergency Fund (CHEF) 
to be administered by the Secretary through the central office 
of the IHS in order to meet the extraordinary medical costs 
associated with the treatment of victims of disasters or 
catastrophic illnesses.
    No part of the CHEF or the administration thereof are to be 
subject to contract or grant, nor shall these funds be 
apportioned on an Area Office, Service Unit, or other similar 
basis. The Secretary is required to promulgate regulations for 
the administration of these funds through negotiated 
rulemaking.
    This section requires that funds appropriated to CHEF not 
be used to offset or limit other appropriations made to the 
IHS. It also requires that all reimbursements to which the IHS 
is entitled by reason of treatment rendered to any victim of a 
disaster or catastrophic illness the cost of which was paid 
from CHEF be deposited back into CHEF.
    Section 203. Health Promotion and Disease Prevention 
Services. This section finds that health promotion and disease 
prevention activities improve health and well-being and reduce 
the expenses for health care, and requires the Secretary to 
provide these services and with input from the affected Tribal 
Health Programs to report to Congress on the status, capacity 
and resources needed to promote health and prevent disease.
    Section 204. Diabetes Prevention, Treatment, and Control. 
Section 204 requires the Secretary to determine the incidence 
of diabetes and its complications among Indians and the 
measures needed to prevent, treat and control it. The Secretary 
is also required, when medically indicated and with informed 
consent, to screen Indians for diabetes and for conditions 
which indicate a high risk for diabetes.
    The Secretary is required to continue to fund model 
diabetes projects and dialysis programs. To the extent that 
funding is available, the Secretary is required to work with 
each Area Office to consult with tribes and tribal 
organizations regarding diabetes programs; establish registries 
in Area Offices; and ensure that data collected are 
disseminated to other Area Offices, subject to privacy laws.
    Section 205. Shared Services for Long-Term Care. This 
section authorizes the Secretary to enter funding agreements 
for delivering long-term care services to Indians. Contents of 
these funding agreements are specified. Any nursing facility 
funded under this section must meet the requirements for such 
facilities under section 1919 of the Social Security Act. In 
addition, the Secretary is required to provide necessary 
technical and other assistance to enable applicants to comply 
with the provisions of this section. The Secretary is required 
to encourage the use of existing underused facilities or allow 
the use of swing beds for long-term or similar care.
    Section 206. Health Services Research. The Secretary is 
required to provide funding for both clinical and nonclinical 
research to further the delivery of Indian health services and 
shall coordinate the activities of other agencies within the 
Department to address this need. Tribal Health Programs are to 
be given equal opportunity to compete for these research funds.
    Section 207. Mammography and Other Cancer Screening. This 
section requires the Secretary, either through the IHS or 
Indian tribes, to provide for mammography and other cancer 
screening consistent with appropriate standards. This section 
does not establish a standard itself, but requires an 
appropriate standard be established which is consistent with 
Title XVIII of the Social Security Act.
    Section 208. Patient Travel Costs. Section 208 requires the 
Secretary to provide funds for the travel costs of patients and 
their appropriate and necessary qualified escorts, associated 
with receiving health care services.
    Section 209. Epidemiology Centers. This section requires 
the Secretary, within 180 days of enactment, to establish and 
fund epidemiology centers in each Service Area without reducing 
the funding levels for centers already established.
    Newly established centers may be operated by Tribal Health 
Programs. The functions of these centers are delineated in this 
section. The Director of the Centers for Disease Control and 
Prevention is required to provide technical assistance to the 
centers and the Secretary is authorized to provide funding to 
tribes, tribal organizations and urban Indian organizations to 
conduct epidemiological studies of Indian communities.
    Section 210. Comprehensive School Health Education 
Programs. Section 210 requires the Secretary to provide funding 
to Indian tribes, tribal organizations and urban Indian 
organizations, for the development of comprehensive school 
health education programs for children from pre-school through 
grade 12. The specific purposes for which funds may be used are 
delineated.
    Upon request, the Secretary is required to provide 
technical assistance in the development and dissemination of 
comprehensive health education plans, materials and 
information. The Secretary, through the IHS and in consultation 
with tribes, tribal organizations and urban Indian 
organizations, shall establish criteria for review and approval 
of applications for this funding.
    Section 211. Indian Youth Program. This section authorizes 
the Secretary to establish and administer programs for 
innovative mental and physical disease prevention and health 
promotion and treatment programs for Indian and Urban Indian 
preadolescent and adolescent youths. Allowable and prohibited 
uses of the funds authorized are delineated.
    The Secretary is required to disseminate information 
regarding models for delivery of comprehensive health care 
services to Indian Youth; to encourage the implementation of 
these models; and provide technical assistance upon request. 
The Secretary is to establish criteria for review andapproval 
of applications under this section, in consultation with tribes, tribal 
organizations and urban indian organizations.
    Section 212. Prevention, Control, and Elimination of 
Communicable and Infectious Diseases. Section 212 authorizes 
the Secretary to fund projects specifically for the purpose of 
preventing, controlling and eliminating communicable and 
infectious diseases. Funding is also authorized for public 
information and education programs, and skills improvement 
activities.
    Demonstration projects for the screening, treatment and 
prevention of hepatitis C virus are also authorized. Funding 
under this section requires an application or proposal for 
funding. Entities which receive funding under this section are 
encouraged to coordinate their activities with the Centers for 
Disease Control and Prevention as well as State and local 
health agencies.
    Finally, in carrying out this section, the Secretary may 
provide technical assistance upon request and shall submit a 
biennial report to Congress on the use of the funds and the 
progress made toward prevention, control, and elimination of 
communicable and infectious diseases among Indians and Urban 
Indians.
    Section 213. Authority for Provision of Other Services. 
This section authorizes the Secretary to fund other activities 
which meet the objectives set forth in section 3 of this Act. A 
partial list of such activities include: hospice care; assisted 
living; long-term health care; home- and community-based 
services; public health functions; and, Traditional Health Care 
Practices.
    Current law authorizes a feasibility study to be conducted 
on these facilities. However, the IHS never completed that 
study and now twelve years later, to conduct such studies would 
greatly delay needed services. The Committee is concerned about 
prohibiting these services from the Indian health care system 
when these types of services have become an accepted part of 
the national health care system and Medicare since 1983.
    Discretion is provided to the IHS, Indian Tribes, or Tribal 
Organizations to provide such care to persons otherwise 
ineligible for the health care benefits of the IHS (subject to 
reimbursement of reasonable charges). The inclusion of these 
individuals is necessary to achieve the minimum patient base 
needed to make the venture financially viable and to stabilize 
the cost efficiencies of providing these services.
    Currently, these types of services are not readily 
available to Native communities. Indians must travel long 
distances only to be placed in facilities which are not 
familiar and not conducive to their well-being as the 
facilities are not culturally-competent. Having culturally-
competent facilities close to Indian communities will promote 
the patient's well-being and enable family members to visit 
without extraordinary cost.
    Section 214. Indian Women's Health Care. This section 
requires the Secretary to provide funds to monitor and improve 
health care for Indian women of all ages. The Committee 
believes the health of Indian women to be vitally important and 
encourages the IHS to heighten attention to addressing diseases 
disproportionately affecting Indian women such as lupus.
    Section 215. Environmental and Nuclear Health Hazards. 
Section 215 requires the Secretary, in conjunction with other 
Federal agencies, to conduct studies and ongoing monitoring 
programs to determine trends in the health hazards to Indian 
miners and other Indians as a result of environmental hazards, 
such as nuclear resource development, petroleum contamination, 
and contamination of water sources and of the food chain.
    Upon completion of such studies the Secretary shall develop 
health plans to address the health problems studied. The 
Secretary is required to submit the study to Congress within 18 
months of enactment and a report no later than 1 year after the 
study which includes recommendations for the implementation of 
the plan and evaluation activities.
    This section establishes an intergovernmental task force to 
identify environmental hazards and to take corrective action. 
The Secretary is to chair this task force, which shall meet at 
least twice yearly. If an Indian, who is employed in or around 
any environmental hazard, suffers from a work-related 
condition, the Indian Health Program which treats him, may be 
reimbursed by the Indian's employer.
    Section 216. Arizona as a Contract Health Service Delivery 
Area. The State of Arizona is designated as a contract health 
service delivery area for providing contract health care 
services to members of Federally-recognized Indian Tribes of 
Arizona. The IHS will not curtail any services as a result of 
this provision.
    These contract health service delivery areas under sections 
216 to 218 have been authorized, but in some cases not 
implemented or funded. The Committee encourages the 
Administration to seek funding for these programs. The 
provisions are subject to appropriations as all discretionary 
programs are, and does not subject the Secretary to retroactive 
liability or application.
    Section 216A. North Dakota as a Contract Health Service 
Delivery Area. The State of North Dakota is designated as a 
contract health service delivery area for providing contract 
health care services to members of Federally-recognized Indian 
Tribes of Arizona. The IHS will not curtail any services as a 
result of this provision.
    Section 216B. South Dakota as a Contract Health Service 
Delivery Area. The State of South Dakota is designated as a 
contract health service delivery area for providing contract 
health care services to members of Federally-recognized Indian 
Tribes of Arizona. The IHS will not curtail any services as a 
result of this provision.
    Section 217. California Contract Health Services Program. 
This section appoints the California Rural Indian Health Board 
(CRIHB) to be a contract care intermediary to improve the 
accessibility of health services to California Indians. The 
Secretary is required to reimburse CRIHB for costs incurred 
pursuant to this section.
    Not more than 5 percent of the amounts provided under this 
section may be for administrative expenses. No payment may be 
made for treatment under this section to the extent payment may 
be made under the Indian Catastrophic Health Emergency Fund or 
from amounts appropriated or otherwise made available to the 
California contract health service delivery area.
    This section also establishes an Advisory Board, comprised 
of representatives from not less than 8 Tribal Health Programs 
serving California Indians covered under this section and at 
least one half of whom are not affiliated with the CRIHB. The 
Advisory Board will advise the CRIHB in carrying out this 
section.
    Section 218. California as a Contract Health Service 
Delivery Area. The State of California, excluding certain 
specified counties, is designated as a contract health service 
delivery area for providing contract health care services to 
California Indians. The excluded counties may be included only 
if finding is specifically provided by the IHS for those 
counties.
    Section 219. Contract Health Services for the Trenton 
Service Area. This section directs the Secretary to provide 
contract health services to members of the Turtle Mountain Band 
of Chippewa Indians that reside in the Trenton Service Area of 
Divide, McKenzie, and Williams counties in North Dakota and the 
counties of Richland, Roosevelt, and Sheridan in Montana. This 
section does not expand the eligibility of members of the 
Turtle Mountain Band of Chippewa Indians for health services 
provided by the IHS beyond the scope of eligibility for these 
services that applied on May 1, 1986.
    Section 220. Programs Operated by Indian Tribes and Tribal 
Organizations. This section requires the IHS to provide funds 
to Tribal Health Programs for health care programs and 
facilities on the same basis as funds are provided to these 
programs operated directly by the IHS.
    Section 221. Licensing or Certification. Section 221 
requires that health care professionals employed by a Tribal 
Health Program, if licensed or certified in any State, be 
exempt from the licensing or certification requirements of the 
State in which the Tribal Health Program provides the services. 
This provision extends similar current authority for the IHS to 
tribal health programs. However, all health professionals must 
still practice within their authorized scope of practice.
    Section 222. Notification of Provision of Emergency 
Contract Health Services. This section allows 30 days (as a 
condition of payment) for an elderly or disabled Indian to 
notify the IHS of any emergency care or health services 
received from a non-IHS provider or in a non-IHS facility.
    Section 223. Prompt Action on Payment of Claims. Section 
223 provides a deadline for the IHS to respond to notification 
of a claim by a provider of a contract care service. The 
section also provides that if the IHS fails to respond within 
the required time, the IHS shall accept the claim as valid. A 
deadline for payment is also provided. This timeframe is 
consistent with the Prompt Payment Act which requires the 
Federal government to pay its claims within 30 days.
    Section 224. Liability for Payment. This section provides 
that a patient who receives authorized contract health care 
services will not be held liable for any charges or costs 
associated with those authorized services. The Secretary is 
required to notify the provider of such services and the 
patient who receives them of the same, within a specified time. 
Following receipt of this notice or an acceptable claim under 
the previous section, a provider has no further recourse 
against the patient who received the health care.
    Section 225. Authorization of Appropriations. This section 
authorizes appropriations as are necessary to carry out this 
title for each fiscal year through 2015.

                         TITLE III--FACILITIES

    Section 301. Consultation; Construction and Renovation of 
Facilities; Reports. This section requires consultation with 
Indian tribes prior to expending construction funds. In 
addition, it sets forth requirements to be met prior to closing 
any facility. This section also establishes and defines 
criteria for the health care facilities priority system, 
including reporting requirements. The responsibility for 
developing the initial comprehensive needs report lies with the 
GAO to ensure that it will get completed. The IHS is then 
charged with the responsibility to update the list as facility 
construction is completed.
    Section 302. Sanitation Facilities. This section provides 
the findings, certain duties for sanitation, authorized uses of 
sanitation funding and facilities, reporting requirements and 
establishes the deficiency levels for those facilities. 
Congress has determined that sanitation is a health issue and 
in 1957 placed the responsibility for sanitation in Indian 
communities with the IHS.
    This section prohibits IHS funding from being used for 
sanitation facilities for new DHUD homes as DHUD provides 
funding for such infrastructure. The IHS funds are limited and 
the backlog, estimated in the billions, so great that such 
funds cannot be diverted to the DHUD Native American Housing 
Assistance and Self-Determination Act block grant without a 
thorough examination of how to balance all the needs associated 
with the sanitation facilities. The Committee believes that 
appropriate flexibility is afforded to the Indian tribes for 
sanitation funding, demonstrated by the fact that over 70% of 
the sanitation funding is contracted by Indian tribes pursuant 
to the ISDEAA.
    Section 303. Preference to Indians and Indian Firms. This 
section authorizes the Secretary to apply Indian preference in 
hiring for certain construction activities.
    Section 304. Expenditure of Nonservice Funds for 
Renovation. This section authorizes the Secretary to accept any 
expansion or renovation funded with non-IHS funds in accordance 
with certain criteria.
    Section 305. Funding for the Construction, Expansion and 
Modernization of Small Ambulatory Care Facilities. This section 
establishes criteria for small ambulatory care facilities, 
including use of funds, priorities and peer review panels. Debt 
reduction has also been included as an authorized use of funds 
within to the Secretary's discretion.
    Section 306. Indian Health Care Delivery Demonstration 
Project. This section authorizes the Secretary to establish 
demonstration projects to test alternative health care delivery 
systems through such methods as hospice care and establishes 
criteria for the projects. The Committee has been made aware 
that the Secretary has not promulgated regulations for these 
projects even though required since 1991. Incentives have been 
added to encourage the Secretary to issue these regulations.
    Section 307. Land Transfer. This section authorizes the 
Secretary to accept any land transferred from the Bureau of 
Indian Affairs for the purpose of providing health care.
    Section 308. Leases, Contracts and Other Agreements. This 
section authorizes the Secretary to enter leases with Indian 
tribes and to consider them operating leases. Federal 
appropriations law requires that all leases be considered 
capital leases unless Congress otherwise designates. This 
provision provides that specific authority by designating the 
leases as operating leases, but gives the Secretary flexibility 
to also designate them as capital leases.
    Section 309. Study for Loans, Loan Guarantees and Loan 
Repayment. This section authorizes a study for the feasibility 
of establishing a loan or loan guarantee fund for Indian health 
care facilities. Initially, this provision established a fund, 
but was reduced to a study due to the objection by the 
Administration. The fund was alleged to (1) disrupt the 
construction priority system; (2) be inconsistent with the 
Credit Reform Act; and (3) be inconsistent with standard 
Federal investment policy. Consequently, the study replaced the 
fund whereby those concerns could be analyzed, among other 
matters. The Committee strongly encourages this study be 
completed as quickly as possible so that additional financing 
options can be made available to Indian tribes.
    Section 310. Tribal Leasing. This section authorizes 
permanent leasing of permanent structures for health services 
without prior approval.
    Section 311. Indian Health Service/Tribal Facilities Joint 
Venture Program. This section authorizes the Secretary to enter 
joint ventures with Indian tribes, provide staffing, equipment 
and supplies for the operation of the facility under a no-cost 
lease with the Indian tribes, in accordance with certain 
criteria.
    A new provision has been added to authorize those Indian 
tribes that have started, but not completed construction, be 
eligible to apply for joint ventures. Indian tribes should not 
be penalized for attempting to address their facility needs 
rather than wait interminably for the IHS to provide funding.
    This new provision is not, however, authorization to 
circumvent appropriate IHS planning and construction 
guidelines. Balancing the criteria and priorities for those 
Indian tribes that are able to start construction and those 
that cannot and must continue to wait are appropriate items for 
negotiated rule-making.
    Section 312. Location of Facilities. This section sets 
forth certain priorities in locating health care facilities to 
address the economically depressed native communities.
    Section 313. Maintenance and Improvement of Health Care 
Facilities. This section requires reporting of backlogs in 
maintenance and improvements for facilities.
    Section 314. Tribal Management of Federally-Owned Quarters. 
This section authorizes the Indian tribes operating a health 
care facility and Federally-owned quarters pursuant to a 
``638'' contract or compact to establish reasonable rental 
rates for the Federally-owned quarters and directly collect the 
rent payments from the employee. It allows Indian tribes to 
take into account the reasonable value of the quarters and the 
amount needed to sustain them. By authorizing direct 
collection, cumbersome bureaucracy is eliminated.
    This provision complements the quarters provisions under 
the ISDEAA, section 105, which directs how rental rates are 
established, but does not take into account appropriate fair 
market values including location costs, nor does it allow 
direct collection of rents.
    Section 315. Applicability of Buy American Act Requirement. 
This section requires application of the Buy American Act for 
all procurement except purchases by Indian tribes or tribal 
organizations under this Act.
    Section 316. Other Funding for Facilities. This section 
authorizes the Secretary to accept funding from other sources 
for the construction of health care facilities and may transfer 
such funds to Indian tribes.
    Section 317. Authorization of Appropriations. This section 
authorizes appropriations through fiscal year 2015.

                  TITLE IV--ACCESS TO HEALTH SERVICES

    Section 401. Treatment of Payments Under Social Security 
Act Health Care Programs. This section requires that any 
Medicare, Medicaid, or State Children's Health Insurance 
Program (SCHIP) payments received by an Indian Health Program 
or Urban Indian Organization shall not be considered in 
determining appropriations for health care services. Indians 
who are covered under these programs will not be given 
preferential treatment over those Indians who are not covered 
by Medicare, Medicaid, or SCHIP. Specifications are made as to 
how funds collected from Medicare, Medicaid, or SCHIP are to be 
used. Finally, this section authorizes Tribal Health Programs 
to directly bill and receive payment from Medicare, Medicaid, 
SCHIP, or third party payors.
    Section 402. Grants to and Funding Agreements with the 
Service, Indian Tribes, Tribal Organizations, and Urban Indian 
Organizations. This section requires the Secretary to make 
grants or other funding agreements with tribes and tribal 
organizations. In doing so, the Secretary shall place 
conditions as deemed necessary to effect the purpose of such 
funding. Additional agreements may be made in order to improve 
the enrollment of Indians under Social Security Act programs 
and to facilitate cooperation with and agreements between 
States, the IHS, Indian Tribes, Tribal Organizations, or Urban 
Indian Organizations. Specifications for applying this section 
to Urban Indian Organizations is included in this section. This 
section also codifies certain requirements contained in current 
regulations for agreement with states for outreach.
    Section 403. Reimbursement From Certain Third Parties of 
Costs of Health Services. Section 403 continues recovery rights 
established since 1988. It authorizes recovery from third 
parties for health services provided to the same extent that an 
individual, or any nongovernmental provider of health services, 
would be eligible to receive damages, reimbursement, or 
indemnification.
    Certain State or local laws are deemed nonapplicable to 
prevent or hinder this right of recovery. This section has no 
effect on private rights of action. Enforcement measures, 
limitations, costs and attorneys' fees are also specified.
    Other items covered in this section are nonapplication of 
claims filing requirements; application to urban Indian 
organizations; statute of limitations; and a savings clause.
    While this provision does not create a cause of action 
within tribal courts, it does allow the parties more options 
for their choice of law provisions in their contracts. It also 
complements ERISA provisions which may apply state law. It also 
does not conflict with ERISA as, under ERISA, jurisdiction is 
exclusive in Federal courts for most causes of action and 
concurrent for the remaining causes of action, with a right of 
removal from state court to Federal court.
    Section 404. Crediting of Reimbursements. This section 
specifies the use of amounts collected and disallows any offset 
or limit of amount obligated from the IHS because of the 
receipt of reimbursements under this section.
    Section 405. Purchasing Health Care Coverage. Section 405 
authorizes funding to be used for purchasing health insurance 
or used for a self-insurance plan providing coverage to 
Indians.
    The purpose of this section is to authorize the purchase of 
insurance through various means instead of, or in addition to, 
establishing health programs, hospitals, clinics, etc., if it 
is a more cost-beneficial means of addressing Indian health 
care needs.
    The purchasers must be mindful of applicable Federal or 
state insurance laws which may affect the purchase or coverage 
for the tribal members. However, the Committee is aware that 
Indian tribes may have many tribal members living in different 
states and should not be prohibited from providing health care 
through insurance coverage.
    This provision authorizes funding to be used to support a 
tribal self-insured plan. The Committee is aware that a tribal 
self-insured plan may include non-eligible beneficiaries who 
are tribal employees.
    The Committee does not wish to discourage Indian tribes 
from hiring individuals deemed to be non-eligible beneficiaries 
under the Act and providing them with benefits, particularly 
the health employees. In fact, the salaries and benefits for 
tribal health employees is already part of the Federal funding 
system, although, arguably, in their capacity as tribal health 
employees, these individuals are not necessarily 
``beneficiaries'' eligible or otherwise.
    Section 406. Sharing Arrangements with Federal Agencies. 
Within certain limitations this section authorizes the 
Secretary to share medical facilities and services with the 
Departments of Veterans Affairs and Defense. If health care 
services are provided to beneficiaries eligible for services 
from either the Department of Veterans Affairs or the 
Department of Defense, then the IHS, Indian Tribe, or Tribal 
Organization providing the service shall be reimbursed from the 
appropriate Department.
    Section 407. Payor of Last Resort. This section specifies 
that Indian Health Programs and health care programs operated 
by Urban Indian Organizations shall be the payor of last resort 
for services provided to eligible persons.
    Section 408. Nondiscrimination in Qualifications for 
Reimbursement for Services. Section 408 requires entities that 
are operated by the IHS, an Indian Tribe, Tribal Organization, 
or Urban Indian Organization to be licensed or recognized under 
State or local law to furnish such services, for purposes of 
receiving payment or reimbursement from any Federally-funded 
health care program. This provision should not be interpreted 
as establishing a payment methodology, but rather it is 
criteria to apply in determining whether the provider is 
eligible for payment.
    Section 409. Consultation. This section establishes a 
National Indian Technical Advisory Group to assist the 
Secretary in identifying and addressing issues regarding health 
care programs under the Social Security Act. This Group is 
critical in identifying and resolving issues and barriers to 
access for Indians.
    Thus, it is necessary that the Urban Indian organizations 
and the IHS be a part of this Group as they serve a majority of 
the Indian beneficiaries. The Group would not be effective 
without these two entities.
    Section 410. State Children's Health Insurance Program 
(SCHIP). This section authorizes the Secretary to arrange with 
individual States to allow SCHIP funds for Indians to be 
provided to the IHS, Indian Tribe, or Tribal Organization for 
providing assistance to such individuals consistent with the 
purposes of SCHIP.
    The Committee is deeply concerned that Indian children are 
not being served even though the Balanced Budget Act of 1997 
specifically mandated that States include provisions in their 
plan explaining how Indian children would be served. Briefings 
before the Committee revealed that the DHHS could not determine 
the number of eligible Indian children nor how many were 
actually served.
    The Committee believes the Administration is committed to 
correcting this issue and has undertaken great efforts to find 
solutions. The Committee believes that Indian tribes could 
provide significant assistance in these efforts, particularly 
in outreach and enrollment.
    Section 411. Social Security Act Sanctions. This section 
authorizes Indian Health Programs to request a waiver of a 
sanction imposed against a health care provider the same way 
that a State may request such a waiver. This provision is 
solely a procedural mechanism for waiver, it does not otherwise 
affect the Secretary's underlying authority to review and 
decide upon waivers.
    The Committee is aware that problems have existed in 
seeking waivers as the Indian tribes may request the State seek 
the waiver and those requests have not been honored. The 
purpose of this provision is not to allow tribal health 
programs to become havens for sanctioned providers, but to 
address, in an appropriate manner, the enormous recruitment 
problems they face.
    The Committee also recognizes that the State, as the 
Medicaid administrator, may also have an interest in commenting 
on the waiver request. The Committee believes the Secretary may 
provide the appropriate avenues for accommodating these 
interests.
    A safe harbor clause is included in this section for 
transaction between and among Indian Health Care Programs. This 
provision will shield the referral system existing between the 
IHS, tribal and urban Indian organizations from criminal 
sanctions. The referrals exist to maintain continuity of care 
for Indian patients and not for monetary gain.
    Section 412. Cost Sharing. This section addresses the 
following areas regarding cost sharing: coinsurance, 
copayments, and deductibles; exemption from Medicaid and SCHIP 
premiums; limitation on medical child support recovery; 
treatment of certain property for Medicaid eligibility; and, 
continuation of current law protections of certain Indian 
property from Medicaid estate recovery.
    The medical child support recovery provisions include 
Indian health programs, not just the IHS. Currently, the 
Department's policy on the Medical Support Enforcement for 
Tribal Members may not cover these additional programs and this 
provision is designed to clarify the coverage.
    The treatment of certain property for Medicaid eligibility 
provision governs the various types of Indian property to be 
excluded when determining eligibility. This provision should be 
given the broadest possible interpretation as Congressional 
policy has provided extensive protections for various types of 
Indian property and taking into account that the purpose of 
these provisions is to increase enrollment, not to find ways to 
exclude Indians from coverage.
    Section 413. Treatment under Medicaid Managed Care. Section 
413 specifies actions to be taken for payment for services 
furnished to Indians in Medicaid managed care programs. This 
section also allows Medicaid managed care programs to be 
offered and gives parameters for such.
    In section 413(b), a State that operates its Medicaid 
program through managed care organizations or primary care case 
managers, is authorized to enter into an agreement with an 
Indian health program or consortium of such programs that 
intend to operate as an MCO or primary care case manager for 
its Indian patients. The Indian health program must still meet 
the State's quality standards, but the State and the Secretary 
are authorized to waive requirements such as enrollment and 
capitalization as needed to facilitate the participation of the 
Indian health programs.
    This provision is not intended to change the Secretary's 
underlying waiver authority or any standards governing such 
waivers. It merely provides the Secretary authority to waive 
taking into account the special circumstances within the Indian 
health system.
    Section 414. Navajo Nation Medicaid Agency Feasibility 
Study. Section 414 requires the Secretary to conduct a study to 
determine the feasibility of treating the Navajo Nation as a 
State for Medicaid purposes. Considerations and a report of the 
study are described in this section.
    Section 415. Authorization of Appropriations. Section 415 
authorizes appropriations of such sums as may be necessary for 
each fiscal year through fiscal year 2015 to carry out this 
title.

               TITLE V--HEALTH SERVICES FOR URBAN INDIANS

    Section 501. Purpose. This section sets forth the purpose 
of the title which is to maintain urban Indian health programs 
to make health services available to urban Indians.
    Section 502. Contracts with, and Grants to, Urban Indian 
Organizations. This section sets forth the authority of the 
Secretary to enter contracts with or make grants to urban 
Indian organizations.
    Section 503. Contracts and Grants for the Provision of 
Health Care and Referral Services. This section sets forth the 
standards, criteria and uses of funds for contracts and grants 
for health care services.
    Section 504. Contracts and Grants for the Determination of 
Unmet Health Care Needs. This section sets forth the standards, 
criteria and uses of funds for contracts and grants to 
determine unmet health care needs of urban Indians.
    Section 505. Evaluations; renewals. This section authorizes 
the Secretary to develop evaluation and renewal standards for 
the various contracts and grants.
    Section 506. Other contract and grant requirements. This 
section sets forth other specific contract and grant 
requirements such as payment methods, procurement and 
amendments.
    Section 507. Reports and Records. This section sets forth 
certain reporting and recordkeeping requirements for urban 
Indian organizations.
    Section 508. Limitation on Contract Authority. This section 
limits contracts to the amount of appropriations.
    Section 509. Facilities. This section sets forth the 
various requirements governing the funding for urban health 
care facilities.
    Section 510. Office of Urban Indian Health. This section 
establishes an Office of Urban Indian Health within the IHS.
    Section 511. Grants for Alcohol and Substance Abuse Related 
Services. This section establishes criteria for alcohol and 
substance abuse grants.
    Section 512. Treatment of Certain Demonstration Projects. 
This section makes permanent certain demonstration projects in 
Oklahoma.
    Section 513. Urban NIAAA Transferred Programs. This section 
authorizes the Secretary to transfer to urban Indian 
organizations alcohol programs that had been previously 
transferred to the Secretary.
    Section 514. Consultation. This section establishes 
consultation requirements with Urban Indian Organizations.
    Section 515. Federal Tort Claim Act Coverage. This section 
authorizes the urban Indian organizations to be deemed an 
executive agency for FTCA coverage.
    Section 516. Urban Youth Treatment Center Demonstration. 
This section authorizes the Secretary to fund at least 2 Indian 
youth treatment centers in certain states where urban centers 
are located.
    Section 517. Use of Federal Property and Supply. This 
section authorizes the Urban Indian Organizations to receive 
donations of Federal excess property and access the Federal 
sources of supply through 40 U.S.C. 501.
    Section 518. Grants for Diabetes Prevention, Treatment and 
Control. This section sets forth requirements and criteria for 
diabetes grants.
    Section 519. Community Health Representatives. This section 
authorizes contracting for community health representatives.
    Section 520. Regulations. This section authorizes the 
promulgation of regulations for this title.
    Section 521. Eligibility for Services. This section 
establishes the beneficiaries of the services under this title.
    Section 522. Authorization of Appropriations. This section 
authorizes appropriations through fiscal year 2015.

                 TITLE VI--ORGANIZATIONAL IMPROVEMENTS

    Section 601. Establishment of the Indian Health Service as 
an Agency of the Public Health Service. Section 601 elevates 
the position of Director of the Indian Health Service to 
Assistant Secretary of Indian Health; and specifies the duties 
and responsibilities of the Assistant Secretary and deems that 
any reference to the Director of the Indian Health Service in 
any Federal law, Executive order, rule, regulation, or 
delegation of authority, etc., refer to the Assistant 
Secretary.
    Section 602. Automated Management Information System. 
Section 602 requires the Secretary to establish an automated 
management information system for the IHS and each Tribal 
Health Program. It requires that patients have access to their 
own health records. It authorizes the Secretary to enter 
contracts, agreements, or joint ventures for the purpose of 
enhancing information technology in Indian health programs and 
facilities.
    Section 603. Authorization of Appropriations. This section 
authorizes appropriated funds in sums that may be necessary to 
carry out this title, for each fiscal year through fiscal year 
2015.

                 TITLE VII--BEHAVIORAL HEALTH PROGRAMS

    Section 701. Behavioral Health Prevention and Treatment 
Services. Section 701 states the purposes of the section; 
requires the Secretary to encourage the development of plans 
for delivery of Indian Behavioral Health Services; directs the 
Secretary to establish a national clearinghouse of plans and 
reports of outcomes; directs the Secretary to provide 
comprehensive behavioral health care programs; facilitates the 
governing body of any Indian Tribe, Tribal Organization, or 
Urban Indian Organization to establish community behavioral 
health plans; requires the Secretary to coordinate behavioral 
health planning; and, directs the Secretary to assess the need, 
availability and cost for inpatient mental health care for 
Indians.
    Section 702. Memoranda of Agreement with the Department of 
the Interior. This section requires the Secretary to develop 
and enter, or review and update, memoranda of agreement with 
the Secretary of the Interior to, among other things, make a 
comprehensive assessment, coordination, and annual review of 
all the behavioral health care needs and services available or 
unavailable to Indians. Specific provisions that are required 
in this memoranda are delineated. Consultation requirements for 
the Secretary are specified. Each memorandum of agreement under 
this section shall be published in the Federal Register.
    Section 703. Comprehensive Behavioral Health Prevention and 
Treatment Program. Section 703 requires the Secretary to 
provide a program of comprehensive behavioral health, 
prevention, treatment, and aftercare. The Secretary may provide 
these services through Contract Health Services.
    Section 704. Mental Health Technician Program. This section 
establishes a mental health technician program within the 
Service, requiring high-standard paraprofessional training in 
mental health care, supervision and evaluation of technicians. 
This program shall involve use and promotion of Traditional 
Health Care Practices of the Indian Tribes to be served.
    Section 705. Licensing Requirement for Mental Health Care 
Workers. This section requires that any person employed as a 
psychologist, social worker, or marriage and family therapist, 
be licensed to provide those services, but does not 
automatically license the professionals.
    Section 706. Indian Women Treatment Programs. Consistent 
with section 701, this section requires that funds be made 
available to develop and implement a comprehensive behavioral 
health program of prevention, intervention, treatment, and 
relapse prevention services, specifically addressing the 
spiritual, cultural, historical, social, and child care needs 
of Indian women.
    Section 707. Indian Youth Program. Consistent with section 
701, this section requires the development and implementation 
of a program for detoxification and rehabilitation of Indian 
Youth. It also establishes alcohol and substance abuse 
treatment centers or facilities for Indian youth. Additional 
provisions addressed in this section are: intermediate 
adolescent behavioral health services; use of Federally-owned 
structures; rehabilitation and aftercare services; inclusion of 
family in youth treatment programs; and multi-drug abuse 
programs.
    Section 708. Inpatient and Community-Based Mental Health 
Facilities Design, Construction, and Staffing. This section 
authorizes the Secretary to provide inpatient mental health 
care facilities in each Service Area.
    Section 709. Training and Community Education. Section 709 
requires that the Secretary, in cooperation with the Secretary 
of the Interior, to provide either directly or through funding, 
a program of community education in the area of behavioral 
health. Specifics of instruction are delineated. This section 
also requires the Secretary to develop and provide community-
based training models.
    Section 710. Behavioral Health Program. This section 
authorizes the development of innovative community-based 
behavioral health programs; suggests criteria to be used for 
funding such programs; and, requires that the same criteria as 
used in evaluating other funding proposals be used for programs 
under this section.
    Section 711. Fetal Alcohol Disorder Funding. Section 711 
establishes fetal alcohol disorder programs, to include the 
development and provision of services for the prevention, 
intervention, treatment, and aftercare for those affected by 
fetal alcohol disorder in Indian communities. In addition a 
Fetal Alcohol Disorder Task Force is established to advise the 
Secretary. Funding is to be made available for applied research 
projects which propose to elevate the understanding of methods 
to prevent, intervene, treat or provide rehabilitation and 
aftercare for Indians affected by this disorder. Urban Indians 
are to be included in these programs.
    Section 712. Child Sexual Abuse and Prevention Treatment 
Programs. This section establishes Child Sexual Abuse and 
Prevention Treatment Programs for both the victims and 
perpetrators of this abuse in Indian households or who are 
Indian. The allowable uses of funds for these programs are 
specified.
    Section 713. Behavioral Health Research. Section 713 
provides for funding for research on the incidence and 
prevalence of behavioral health problems among Indians. 
Research priorities are specified.
    Section 714. Definitions. This section provides definitions 
for the following terms used in this title: assessment; 
alcohol-related neurodevelopmental disorders or ARND;behavioral 
health aftercare; dual diagnosis; fetal alcohol disorders; fetal 
alcohol syndrome or FAS; partial FAS; rehabilitation; and substance 
abuse.
    Section 715. Authorization of Appropriations. This section 
authorizes such sums as may be necessary to carry out this 
section, for each fiscal year through fiscal year 2015.

                       TITLE VIII--MISCELLANEOUS

    Section 801. Reports. This section outlines the various 
reporting requirements under this Act.
    Section 802. Regulations. This section sets forth the 
various requirements for regulations, including negotiated 
rule-making, under this Act.
    Section 803. Plan of Implementation. This section requires 
a plan of implementation of this Act to be submitted to 
Congress.
    Section 804. Availability of Funds. This section authorizes 
funding to remain available until expended.
    Section 805. Limitation on Use of Funds Appropriated to the 
IHS. This section establishes certain limitations on the use of 
funds.
    Section 806. Eligibility of California Indians. This 
section clarifies the eligibility for the Indians located in 
California.
    Section 807. Health Services for Ineligible Persons. This 
section authorizes services for certain ineligible persons 
under limited circumstances and outlines criteria for providing 
services.
    Section 808. Reallocation of Base Services. This section 
limits the reallocation of base funding upon certain 
requirements the Secretary must fulfill.
    Section 809. Results of Demonstration Projects. This 
section requires that results of demonstration projects be made 
available to Indian tribes.
    Section 810. Provision of Services in Montana. This section 
recognizes a court decision governing services for certain 
Indians in Montana whereby the IHS is responsible for making 
payment for Indians' health care expenses when other funds have 
been exhausted and are not available. McNabb v. Bowen, 829 F.2d 
787 (9th Cir. 1987).
    Section 811. Moratorium. This section authorizes the IHS to 
provide certain services according to eligibility criteria in 
effect on a certain date.
    Section 812. Tribal Employment. This section recognizes the 
governmental purposes of health care by treating Indian tribes 
or tribal organizations not as an employer for certain 
purposes.
    Section 813. Prime Vendor. This section recognizes tribal 
health programs as an executive agency for accessing the 
Federal sources of supply and streamlines access. This 
provision authorizes direct access for Indian tribes to the 
sources of supply rather than accessing through the IHS.
    Section 814. Severability Provisions. This section retains 
remaining provisions if others are stricken by any court.
    Section 815. Establishment of National Bipartisan 
Commission on Indian Health Care Entitlement. This section 
establishes a commission to study Indian health care as an 
entitlement, including duties, membership and reports. This 
Commission is to collect data on the extent of Indian health 
care needs, including conducting hearings, studying models for 
providing health care. After the study, the Commission is to 
make recommendations for legislation providing for Indian 
health care as an entitlement, including eligibility, benefits, 
costs, and impact on the current Indian health care system. The 
Commission consists of 25 members, including Members of 
Congress and Indian tribes.
    Section 816. Appropriations; Availability. This section 
subjects new spending to the availability of funding.
    Section 817. Confidentiality of Medical Quality Assurance 
Records: Qualified Immunity for Participants. This section 
establishes requirements for quality assurance such as 
confidentiality, privacy, disclosure and liability and sets 
forth the limits on such disclosure to promote the free 
exchange of information and recommendations from the health 
professionals and employees.
    Section 818. Authorization of Appropriations. This section 
authorizes appropriations through fiscal year 2015.

                       OTHER SECTIONS OF THE BILL

    Section 2(b) and (c). Section 2(b) and (c) of the bill sets 
forth provisions of the bill amending other laws such as the 
references to the ``Director of Indian Health Service'' which 
would be changed to ``Assistant Secretary for Indian Health''; 
and amendments to the Three Affiliated Tribes and Standing Rock 
Sioux Tribe Equitable Compensation Act which authorizes funding 
to rebuild a health care facility.
    Section 3. Section 3 of the bill retains authorization for 
sanitation facilities to the Soboba Band of Mission Indians.
    Section 4. Section 4 of the bill sets forth amendments to 
the Medicaid and SCHIP which authorize reimbursement to Indian 
health programs for medical assistance provided.

                   Cost and Budgetary Considerations

    Due to time constraints, the cost estimate for S. 556 is 
not included in this Report. When it is received by the 
Committee, the cost estimate will be included in the 
Congressional Record.

                      Regulatory Impact Statement

    Paragraph 11(b) of rule XXVI of the Standing Rules of the 
Senate requires each report accompanying a bill to evaluate the 
regulatory and paperwork impact that would be incurred in 
carrying out the bill. The Committee believes that S. 556 will 
have minimal regulatory or paperwork impact.

                        Executive Communications

    The Committee received oral and written testimony from the 
U.S. Department of Health and Human Services at the hearing on 
S. 556 held on April 2, 2003, July 16, 2003 and July 21, 2004. 
The Committee received oral and written testimony from the U.S. 
Department of Housing and Urban Development at the hearing on 
S. 556 held on July 16, 2003. The written testimony is attached 
as follows:

Statement of Charles W. Grim, D.D.S., M.H.S.A, Interim Director, Indian 
                             Health Service

    Mr. Chairman and Members of the Committee:
    Good morning, I am Dr. Charles Grim, Interim Director of 
the Indian Health Service (IHS). Today, I am accompanied by Mr. 
Michel Lincoln, Deputy Director, Mr. Gary Hartz, Acting 
Director of the Office of Public Health, and Dr. Craig 
Vanderwagen, Director, Division of Clinical and Preventive 
Services, Office of Public Health. We are pleased to have this 
opportunity to testify on behalf of Secretary Thompson on S. 
556, the Indian Health Care Improvement Act Reauthorization of 
2003''. And, at the Committee's request, I will report on the 
Secretary's One-Department Initiative as it impacts the IHS and 
the president's FY 04 budget proposal to consolidate automated 
information systems in the Department.
    The IHS has the responsibility for the delivery of health 
services to more than 1.6 million Federally-recognized American 
Indians and Alaska Natives (AI/ANs) through a system of IHSA, 
tribal and urban (I/T/U) operated facilities and programs based 
on treaties, judicial determinations, and Acts of Congress. The 
mission of the agency is to raise the physical, mental, social, 
and spiritual health of AI/ANs to the highest level, in 
partnership with the population we serve. The agency goal is to 
assure that comprehensive, culturally acceptable personal and 
public health services are available and accessible to the 
service population. Our foundation is to uphold the Federal 
government obligation to promote healthy American Indian and 
Alaska Native people, communities, and cultures and to honor 
and protect the inherent sovereign rights of tribes.
    Two major pieces of legislation are at the core of the 
Federal government's responsibility for meeting the health 
needs of American Indians/Alaska Natives (AI/ANs): The Snyder 
Act of 1921, P.L. 67-85, and the Indian Health Care Improvement 
Act (IHCIA), Public Law 94-437. The Snyder Act authorized 
regular appropriations for ``the relief of distress and 
conservation of health'' of American Indian/Alaska Natives. The 
IHCIA was enacted ``to implement the Federal responsibility for 
the care and education of the Indian people by improving the 
services and facilities of Federal Indian health programs and 
encouraging maximum participation of Indians in such 
programs.'' Like the Snyder Act, the IHCIA provided the 
authority for the programs of the Federal government that 
deliver health services to Indian people, but the IHCIA also 
provided additional guidance in several areas. The IHCIA 
contained specific language that addressed the recruitment and 
retention of a number of health professionals serving Indian 
communities focused on health services for urban Indian people 
and addressed the construction, replacement, and repair of 
health care facilities.
    We are here today to discuss reauthorization of the IHCIA 
and tribal recommendations for change to the existing IHCIA in 
the context of the many changes that have occurred in our 
country's health care environment since the law was first 
enacted in 1976. S. 556 reflects the product of an extensive 
tribal consultation process that took two full years and 
resulted in a tribally drafted reauthorization bill. IHS staff 
provided technical assistance and support to the Indian tribes 
and urban Indian health programs through this lengthy 
consultation.
    The Department supports the purposes of S. 556 to improve 
the health status of AI/AN people and to raise health status 
the highest possible level. We do, however, continue to have 
concerns, as expressed previously to the Committee in the 
Secretary's September 27, 2001 report on S. 212, regarding a 
number of provisions in that bill. As introduced, S. 556 is 
identical to S. 212. There are several provisions in S. 556 
that are inconsistent with current Medicare and Medicaid 
provider payment practices and could inappropriately increase 
costs. For example:
     Title II, Section 202, which describe a new 
provider type called a Qualified Indian Health Provider (QIHP) 
and Sections 212 and 221 regarding extension of the 100% 
Federal matching rate for Medicaid and SCHIP. These sections 
are further discussed below in the statement.
     In addition, Section 419 proposes to exempt 
patients eligible for Medicare or Medicaid from standard cost-
sharing requirements such as deductibles, co-payments, and 
premiums. We have no concern with the current exception for 
Indian children exempt from premiums and co-pays in the SCHIP 
program.
    The Department also reported in the staff analysis of its 
September 27, 2001 bill report some concerns with the managed 
care provisions in Section 423 which limits appropriate cost 
and utilization incentives in Medicare and Medicaid by 
potentially undermining capitated payments in managed care 
settings.
    The Administration is seriously concerned about these 
provisions, which undermine standard practices in Medicare and 
Medicaid. The most pressing concerns were outlined in the 
Secretary's September report which I will present to you today: 
(1) the Qualified Indian Health Program (QIHP); (2) negotiated 
rule making; and (3) extension of 100% Federal matching rate 
for Medicaid and SCHIP.
    While the Administration continues to have serious concerns 
about S. 556 in its current form, we are committed to working 
with the Committee on legislation to reauthorize this important 
cornerstore authority for the provision of health care to 
American Indians and Alaska Natives.


                 qualified indian health program (qihp)


    The bill would amend the Medicare statute to add various 
detailed provisions for a new provider type called a Qualified 
Indian Health Provider (QIHP) for IHS, Tribal, and urban Indian 
(I/T/U) providers participating in the Medicare and Medicaid 
programs. The most problematic aspects of QIHP are the 
structure and operation of the payment provisions, which are 
not only burdensome but, more importantly, would not be 
feasible to administer. QIHP would require the Federal 
government to complete a series of complex payment computations 
for each I/T/U provider, for each payment period, (including 
rates and adjustments not available to any other provider) to 
identify the provider type for each that yields the highest 
payment amount for that period. However, such computations 
could only be made after services are provided, when it is too 
late for the providers to have known or complied with the 
differing conditions of participation applicable to differing 
provider types. In addition to the burden and feasibility 
issues, on a more fundamental level, this ``full cost plus 
other costs'' QIHP payment approach would be contrary to the 
way that Medicare generally pays providers. Moreover, it would 
impose disproportionately higher costs on a program that is 
approaching insolvency. Extending such a payment approach to 
Medicaid and SCHIP would raise similarly serious administrative 
and budgetary concerns.


  negotiated rule making; tribal consultation; administrative burdens


    We are concerned that S. 556 would appear to broadly 
mandate use of negotiated rule making to develop all 
regulations to implement the IHCIA. Negotiated rule making is 
very resource-intensive for both Federal and non-Federal 
participants. It can be effective in appropriate circumstances, 
but may not be the most effective way to obtain necessary 
Indian provider input in the development of IHCIA rules and 
regulations in a given case.
    Additionally, while we appreciate the value of consultation 
with Tribes, we have concerns about the consultation 
requirements. The bill would require Tribal consultation prior 
to the Centers for Medicare & Medicaid Services (CMS) adopting 
any policy or regulation, as well as require all HHS agencies 
to consult with urban Indian organizations prior to taking any 
action, or approving any action of a State, that may affect 
such organizations or urban Indians. Such requirements appear 
to be broader than the existing Tribal consultation requirement 
and would be very difficult to administer, given the hundreds 
of regulations and policies potentially covered.
    We have similar concerns about the considerable indirect 
adverse impact of S. 556's extensive reporting requirements and 
other administrative burdens on IHS and CMS that would divert 
limited resources from other activities. One example is the 
proposed requirement for a detailed annual report on health 
care facilities construction needs and the survey of facilities 
it would entail. As IHS programs and both IHS and CMS 
administrative functions are funded by capped discretionary 
accounts, the imposition of additional administrative duties on 
IHS and CMS would have the practical effect of requiring 
cutbacks in current activities.

     extension of 100% federal matching rate for medicaid and schip

    We also are concerned that the bill would extend the 100% 
Federal matching rate to States for Medicaid and State 
Children's Health Insurance Program (SCHIP) services (currently 
applicable to such services provided through an IHS facility) 
to other services provided to American Indians and Alaska 
Natives, including those furnished by non-Indian health care 
providers. This proposed change would substantially increase 
Federal program and administrative costs, with no guarantee and 
little likelihood of any more services for Indian beneficiaries 
or better payments for Indian providers.
    As we continue our thorough review of this far-reaching, 
complex legislation, we may have further comments. However, we 
wish to reiterate our strong commitment to reauthorization and 
improvement of the Indian health care programs. We will be 
happy to work with the Committee, the National Tribal Steering 
Committee, and other representatives of the American Indian and 
Alaska Native communities to develop a bill fully acceptable to 
all stakeholders in these important programs.


                       one-department initiative


    In addition to our expressed concerns with S. 556, I will 
now present an explanation of the Secretary's One-Department 
initiative and its benefit to the IHS.
    The Secretary's One Department Initiative has been of great 
benefit to the IHS as well as the Native American constituents 
of the Department. The fundamental premise of this initiative 
is that the Department of Health and Human Services must speak 
with one, consistent voice. Nothing is more important to our 
success as a department. With regard to our tribal constituents 
the Secretary observed on his first trip to Indian Country that 
tribal programs were often ``stove piped'' and that there 
existed within HHS an assumption that the IHS had sole 
responsibility for the health issues facing tribes. In the two 
short years since the Secretary launched this initiative he has 
reestablished the Intradepartmental Council for Native American 
Affairs. The membership of this Council is comprised of the 
heads of all the HHS Operating and Staff Division with the IHS 
Director serving as the Vice-Chair. This Council serves as an 
advisory body to the Secretary and has the responsibility to 
assure that Indian policy is implemented across all Divisions. 
The Council provides the Secretary with policy guidance and 
budget formulation recommendations that span all Divisions of 
HHS. A profound impact of this Council on the IHS is the 
revised premise within HHS that all Agencies bear 
responsibility for the government's responsibility and 
obligation to the Native people of this country.
    In addition to the Council the Secretary and Deputy 
Secretary have traveled widely to Indian Country with their 
senior staff. These trips have raised the awareness of tribal 
issues and have contributed greatly to our capacity to speak 
with one voice on behalf of tribes.
    An example of a tangible benefit to the IHS is the FY '04 
President's budget request for IHS of $20 million for 
Sanitation Facilities Program. An evaluation of the program 
justified an increase in the FY '04 budget for the program's 
most needy homes. This increase was also a result of the 
Secretary's visit to Alaska with his senior staff in 2002. They 
observed the critical need for safe drinking water and 
sanitation facilities in Indian Country and acted decisively to 
increase the IHS budget request.
    The One Department Initiative can be directly credited for 
this step forward for the Native people of this nation.


              fy '04 information technology consolidation


    Also, I would like to address the Committee's request for 
information on the FY '04 President's budget proposal to 
consolidate automated information systems in the Department.
    The FY '04 President's Budget for IHS includes funding to 
support Departmental efforts to improve the HHS Information 
Technology Enterprise Infrastructure. The request includes 
funds to support an enterprise approach to investing in key 
information technology infrastructure such as security and 
network modernization.
    These investments will enable IHS programs to carry out 
their missions more securely and at a lower cost. Agency funds 
will be combined with resources in the IT Security and 
Innovation Fund to promote collaboration in planning and 
project management and to achieve common goals such as secure 
and reliable communication and lower costs for the purchase and 
maintenance of hardware and software.
    The IHS budget request includes savings in the IT Budget 
from ongoing IT consolidation efforts and additional reduced 
spending through the streamlining or elimination of lower 
priority projects. As a result, the FY '04 IHS budget request 
proposed a decrease in spending for information technology 
below the FY '03 level of $9,282,000. This decrease is the 
result of IT savings associated with the creation of ``one 
HHS'' from the Department's disparate organization units and 
more efficient and effective management of the base HHS 
information technology system. Consolidation of IT resources 
will yield savings necessary to support program requirements.
    Mr. Chairman, this concludes my statement. Thank you for 
this opportunity to discuss the reauthorization of the Indian 
Health Care Improvement Act and other issues. We will be happy 
to answer any questions that you may have.

   Statement of Charles W. Grim, D.D.S., M.H.S.A., Interim Director, 
                         Indian Health Service

    Mr. Chairman and Members of the Committees:
    Good morning, I am Dr. Charles Grim, Interim Director of 
the Indian Health Service (IHS). Today, I am accompanied by Mr. 
Gary Hartz, Acting Director of the Office of Public Health; Dr. 
Richard Olson, Acting Director, Division of Clinical and 
Preventive Services, Office of Public Health; and Rae Snyder, 
Acting Director of the Urban Health Office. We are pleased to 
have this opportunity to testify on behalf of Secretary 
Thompson on S. 556, the Indian Health Care Improvement Act 
Reauthorization of 2003. And, at the Committee's request, I 
will discuss the health disparities, Indian health facilities 
and urban Indian health concerns.
    The IHS has the responsibility for the delivery of health 
services to more than 1.6 million Federally-recognized American 
Indians and Alaska Natives (AI/ANs) through a system of IHS, 
tribal, and urban (I/T/U) operated facilities and programs 
based on treaties, judicial determinations, and Acts of 
Congress. The mission of the agency is to raise the physical, 
mental, social, and spiritual health of AI/ANs to the highest 
level, in partnership with the population we serve. The agency 
goal is to assure that comprehensive, culturally acceptable 
personal and public health services are available and 
accessible to the service population. Our foundation is to 
uphold the Federal Government's obligation to promote healthy 
American Indian and Alaska Native people, communities, and 
cultures and to honor and protect the inherent sovereign rights 
of Tribes.
    Two major pieces of legislation are at the core of the 
Federal Government's responsibility for meeting the health 
needs of American Indians/Alaska Natives (AI/ANs): The Snyder 
Act of 1921, P.L. 67-856, and the Indian Health Care 
Improvement Act (IHCIA), P.L. 94-437. The Snyder Act authorized 
regular appropriations for ``The relief of distress and 
conservation of health'' of American Indians/Alaska Natives. 
The IHCIA was enacted ``to implement the Federal responsibility 
for the care and education of the Indian people by improving 
the services and facilities of Federal Indian health programs 
and encouraging maximum participation of Indians in such 
programs.'' Like the Snyder Act, the IHCIA provided the 
authority for the programs of the Federal Government that 
deliver health services to Indian people, but the IHCIA also 
provided additional guidance in several areas. The IHCIA 
contained specific language that addressed the recruitment and 
retention of a number of health professionals serving Indian 
communities focused on health services for urban Indian people 
and addressed the construction, replacement, and repair of 
health care facilities.
    We are here today to discuss reauthorization of the IHCIA 
and tribal recommendations for change to the existing IHCIA in 
the context of the many changes that have occurred in our 
country's health care environment since the law was first 
enacted in 1976. S. 556 reflects the product of an extensive 
tribal consultation process that took two full years and 
resulted in a tribally drafted reauthorization bill. IHS staff 
provided technical assistance and support to the Indian Tribes 
and urban Indian health programs through this lengthy 
consultation. however, we recognize that our programs overlap 
and have implications for other Federal agencies and their 
programs, and we are working with them to develop a 
comprehensive Administration position on this legislation.


                           HEALTH DISPARITIES


    While the mortality rates of Indian people have improved 
dramatically over the past ten years, Indian people continue to 
experience health disparities and death rates that are 
significantly higher than the rest of the U.S. general 
population:
           Alcoholism--770% higher
           Diabetes--420% higher
           Accidents--280% higher
           Suicide--190% higher
           Homicide--210% higher
    Those statistics are startling, yet they are so often 
repeated that some view them as insurmountable facts. But every 
one of them is influenced by behavior choices and lifestyle. 
Making significant reductions in health disparity rates, and 
even eliminating them, can be achieved by implementing best 
practices, using traditional community values, and building the 
local capacity to address these health issues and promote 
healthy choices.
    A primary area of focus that I have identified based on 
these statistics is a renewed emphasis on health promotion and 
disease prevention. I believe this will be our strongest front 
in our ongoing battle to eliminate health disparities plaguing 
our people for far too long. Although we have long been an 
organization that emphasizes prevention, I am calling on the 
Agency to undertake a major revitalization of its public health 
efforts in health promotion and disease prevention. Both field 
and tribal participation in the initial stages of planning and 
implementation is critical.
    Fortunately, the incidence and prevalence of many 
infectious diseases, once the leading cause of death and 
disability among American Indians and Alaska Natives, have 
dramatically decreased due to increased medical care an public 
health efforts that included massive vaccination and sanitation 
facilities construction programs. Unfortunately, as the 
population lives longer and adopts more of a western diet and 
sedentary lifestyle, chronic diseases emerge as the dominant 
factors in the health and longevity of the Indian population 
with the increasing rates of cardiovascular disease, Hepatitis 
C virus, and diabetes.
    Cardiovascular disease is now the leading cause of 
mortality among Indian people, with a rising rate that is 
significantly higher than that of the U.S. General population. 
This is a health disparity rate that the President, the 
Secretary of Health and Human Services, and the IHS are 
committed to eliminating. The IHS is working with other HHS 
programs, including the Centers for Disease Control and 
Prevention and the National Institutes of Health's National 
Heart Lung and Blood Institute, to develop a Native American 
Cardiovascular Disease Prevention Program. Also contributing to 
the effort is the IHS Diabetes Program, the IHS Disease 
Prevention Task Force, and the American Heart Association. The 
primary focus is on the development of more effective 
prevention programs for AI/AN communities. The IHS has also 
begun several programs to encourage employees and our tribal 
and urban Indian health program partners to lose weight and 
exercise, such as ``Walk the Talk'' and ``Take Charge 
Challenge'' programs.
    Diabetes mortality rates have been increasing at almost 
epidemic proportions. American Indians and Alaska Natives have 
the highest prevalence of type 2 diabetes in the world. The 
incidence of type 2 diabetes is rising faster among American 
Indians and Alaska Native children and young adults than in any 
other ethnic population, and is 2.6 times the national average. 
As diabetes develops at younger ages, so do related 
complications such as blindness, amputations, and end stage 
renal disease. Today I want to report to you that we may be 
seeing a change in this pattern however. In CY 2000 we have 
observed for the first time ever a decline in mortality. I must 
note that this is preliminary mortality data that needs to be 
thoroughly examined.
    What is most distressing however about these statistics is 
that type 2 diabetes is largely preventable. Lifestyle changes, 
such as changes in diet, exercise patterns, and weight can 
significantly reduce the changes of developing type 2 diabetes. 
Focusing on prevention not only reduces the disease burden for 
a suffering population, but also lessens and sometimes 
eliminates the need for costly treatment options. The cost-
effectiveness of a preventative approach to diabetes management 
is an important consideration, since the cost of caring of 
diabetes patients is staggering. Managed care estimates for 
treating diabetics range from $5000-$9000 per year. Since the 
Indian health system currently cares for approximately 100,000 
people with diagnosed diabetes, this comes out to a 
conservative estimate of $500 million just to treat this one 
condition.
    Another area of concern is in behavioral health, 
specifically the identification and treatment of depression and 
strategies for prevention of depression. A recent study from 
Washington University in St. Louis has revealed that untreated 
depression doubles the risk for chronic diseases like diabetes 
and cardiovascular disease, not to mention the risks for 
alcoholism, suicide, and other violent events. This study also 
showed that of those individuals with chronic disease, 
unrecognized and untreated depression doubles the risk for 
complications of the chronic disease (e.g., amputations and 
renal disease in diabetics). We must find the best practices 
that will allow us to prevent depression primarily, or at the 
least recognize and treat it early if we are to reduce the 
disparities that affect Indian communities.
    In summary, preventing disease and injury is a worthwhile 
financial and resource investment that will result in long-term 
savings by reducing the need for providing acute care and 
expensive treatment processes. It also yields the even more 
important humanitarian benefit of reducing pain and suffering, 
and prolonging life. This is the path we must follow if we are 
to reduce and eliminate the disparities in health that so 
clearly affect AI/AN people.


                         HEALTH CARE FACILITIES


    Title III authorizes the Facilities programs which 
construct, renovate, maintain, and improve facilities where 
Indian health services are provided. Sanitation facilities 
construction is conducted in 38 States with Federal recognized 
Tribes where ownership of the facilities is turned over to the 
Tribes to operate and maintain them once completed. The IHS 
health care facilities program including the tribal programs, 
specifically, is responsible for managing and maintaining the 
largest inventory of real property in the Department of Health 
and Human Services, with over 9 million square feet (850 gross 
square meters) of space. There are 49 hospitals, 231 health 
centers, 5 school health centers, over 2000 units of staff 
housing, and 309 health stations, satellite clinics, and Alaska 
village clinics which support the delivery of health care to 
our people. These facilities authorizations put in place the 
foundation on which health care delivery is provided to 
American Indians and Alaska Natives.
Health care facilities needs assessment and report
    Proposed provisions in the IHCIA reauthorization bills 
require IHS to report annually, after consultation with Tribes, 
on the needs for health care facilities construction, including 
the renovation and expansion needs. In fact, efforts are 
currently underway to develop a complete description of need 
similar to what would be required by the Bill. While not all 
the resource issues have been resolved, the process is in 
progress and the plan is to base our future facilities 
construction priority system methodology application on a more 
complete listing of tribal and Federal facilities needs for 
delivery of health care services funded through the IHS. We 
will continue to explore with the Tribes less resource 
intensive means for acquiring and updating the information that 
would be required in these reports.
Using sanitation facilities construction funds to serve HUD homes
    Section 302(b)(3)(C) specifically proposes that IHS 
sanitation facilities construction funds will not be used to 
support service of sanitation facilities to Department of 
Housing and Urban Development (HUD) homes. The IHS is concerned 
that homes constructed using HUD funds include the necessary 
infrastructure to make a home complete, including safe water 
and sewer and wastewater disposal.
    As you know, the Administration is actively reviewing S. 
556 and will provide you with specific details of our analysis 
very shortly. We are committed to working with Tribes and other 
agencies to ensure that adequate facilities are planned for and 
funded in conjunction with new home construction, and we 
appreciate HUD's and other Federal agencies' willingness to 
work with us in this regard.
Classifying long term leases as operating leases
    Proposed provisions of the bills would make it possible to 
classify a lease for health care space as an operating lease 
and allow for long term leases for space (capital leases) to be 
scored against the budget in the first year of the lease. The 
intent of the proposed section is to make it possible for 
Tribes to acquire a facility and enter into a long term lease 
with the Government without having the full cost of the lease 
scored against a single year's budget. While this may make it 
possible for Tribes to more easily acquire needed space to 
house health care services, there is concern that leasing 
capital space in this manner will commit future Congresses and 
Administrations to funding without the opportunity for review.
Retroactive funding of Joint Venture Construction Projects
    Changes proposed by the bills would permit a tribe that has 
``begun or substantially completed'' the process of acquisition 
of a facility to participate in the Joint Venture Program, 
regardless of government involvement or lack thereof in the 
facility acquisition. An agreement implies that all parties 
have been party to the development of a plan and have arrived 
at some kind of consensus regarding the actions to be taken. By 
permitting a tribe that has ``begun or substantially 
completed'' the process of acquisition or construction, the 
proposed provisions could force IHS to commit the government to 
support already completed actions that have not included the 
government in the review and approval process. We are concerned 
that this language could put the government in the position of 
accepting space that is inefficient and/or ineffective to 
operate.
Sanitation facilities deficiency definitions
    Proposed new language in the bills, which provides 
definitions of sanitation deficiencies used to identify and 
prioritize water and sewer projects in Indian Country, is 
ambiguous. As written deficiency level III could be interpreted 
to mean all methods of service delivery are adequate to level 
III requirements (including methods where water and sewer 
service provided by hauling rather than through piping systems 
directly into the home) and only the operating condition, for 
example frequent service interruptions, make that facility 
deficient. This description assumes that water haul delivery 
systems and piped systems provide a similar level of service. 
We believe that there should be a distinction.
    In addition, the definition for Deficiency Level V and 
Deficiency Level IV, through phrased differently, have 
essentially the same meaning. Level IV should refer to an 
individual home or community lacking either water or wastewater 
facilities, whereas, level V should refer to an individual home 
or community lacking both water and wastewater facilities.
Tribal management of federally-owned quarters
    The bills reiterate authorization already provided in the 
Indian Self-Determination and Education Act (P.L. 93-638, as 
amended). We are concerned that slight differences in wording 
in the two bills either as written or in amendments could cause 
confusion. We believe that this proposed addition of 
unnecessary language should be deleted.
Threshold criteria for small ambulatory program
    The Small Ambulatory Care Facility section contains 
proposed language that limits participation in the Small 
Ambulatory Program to facilities that provide more than 500 
visits to eligible users and that provide ambulatory care in a 
service area with a population of more than 1,500 eligible 
Indians. These criteria are both lower limits and would apply 
to many facilities including all large health centers, most of 
which also qualify for priority evaluation and possible funding 
under Section 301 of the two bills. We are concerned that some 
facilities that meet these criteria may be of a lower priority 
than those on the Priority List submitted to Congress and could 
receive construction funding before higher priority 
construction needs. We do, however, see a need for a Small 
Ambulatory Program that addresses the needs of Tribes with 
smaller facilities that do not meet the threshold to compete 
for placement on the Section 301 Priority Lists. For that 
reason we recommend that this section set an upper threshold 
criterion of 4,400 primary care provider visits for 
participation in the Small Ambulatory Program. The lower limit 
should be 500 primary care provider visits. The Small 
Ambulatory Program is to address the needs of small tribal 
facilities that are not competitive under the Section 301 
Priority System because of their size.


                          URBAN INDIAN HEALTH


    The Title V of the IHCIA provides specific authority 
focused on the provision of health services for urban Indian 
people with funds appropriated to IHS. IHS currently funds 34 
urban Indian programs nationally and these programs provide a 
range of services in three broad categories: comprehensive 
clinical programs; limited clinical programs; and outreach and 
referral programs.
    In addition to the 34 urban Indian health programs 
currently in operation, the Congress has also authorized and 
funded the Oklahoma City Clinic and Tulsa Clinic Demonstration 
Programs. Both the Oklahoma City Indian Clinic and the Tulsa 
Indian Clinic (now the Indian Health Care Resource Center of 
Tulsa) were established in the early 1970's to serve the health 
and social needs of the urban Indian populations of Oklahoma. 
With the passage of the Indian Health Care Improvement Act in 
September 1976, these two programs were funded by the Indian 
Health Service (IHS) under Title V of that law as urban 
programs.
    In 1978, the entire State of Oklahoma was designated as a 
Contract Health Service Delivery Area (CHSDA) by regulation (42 
CFR 36.22(a)(3)). As a statewide CHSDA Indian beneficiaries 
could reside anywhere in the state and maintain their 
eligibility for both direct services and contract health 
services. As a result of this change, the Oklahoma Indian 
population count for services was inclusive of all Indians 
residing in the state and counted as IHS beneficiaries in the 
IHS calculation for resource requirements and allocations.
    The 1992 amendments to IHCIA provided for the establishment 
of two demonstration projects with the Tulsa and Oklahoma City 
clinics, ``to be treated as service units in the allocation of 
resources and coordination of care.'' In establishing these 
demonstration projects Congress undertook a new and innovative 
approach to ensuring health services were accessible to all 
eligible populations in Oklahoma.
    These demonstration projects have now established a 
``hybrid'' system within the IHS and have a unique status. The 
projects are not operated strictly as an IHS facility or tribal 
contracted or compacted program or an urban program. Each 
program maintains its status under the Title V as an ``urban 
Indian organization.'' Contracts are signed by the projects 
with the IHS, under Title V and the Buy Indian Act authority, 
yet the programs function like other IHS service units and 
report on the Resources and Patient Management System of the 
IHS with data utilized for inclusion in the allocation of 
resources. This unique status has allowed for a substantive 
increase in funds to the projects from the IHS based upon 
workload data and increases derived from substantial line-item 
funding increases directed by Congress in fiscal year 1994 
addressing facility problems at each site. Both service 
population and overall utilization of services has dramatically 
increased since these programs became demonstration projects 
and as a result of the line item funds. They have been able to 
use the best of both urban and IHS structures to build a 
community controlled, high quality health system in a state 
designated as a contract health service delivery area.
    On the other hand this hybrid system has raised a few 
concerns with some Oklahoma Tribes the operate their own health 
programs under the Indian Self Determination and Education 
Assistance Act, P.L. 93-638, as amended. The issue in most 
basic terms is allocation of resources for tribally 
administered services and urban provided services for closely 
located beneficiary populations. In an environment of resources 
reduced by a growing population and greater health need, the 
perception of a unique or special status may cause more concern 
than has been observed in the past.
    While the challenges for the urban Indian health programs 
are many, they are much the same as those faced by the Tribes 
and the federal operations. Our work is to assure that we all 
are working to fulfill our roles in the I/T/U partnership and 
in collaboration to raise the health status of our Indian 
people.


   NEGOTIATED RULEMAKING; TRIBAL CONSULTATION; ADMINISTRATIVE BURDENS


    While the Administration continues to have serious concerns 
about the proposed bills in their current forms, we are 
committed to working with the Committees on legislation to 
reauthorize this important cornerstone authority for the 
provision of health care to American Indians and Alaska 
Natives.
    We are concerned that both bills would appear to broadly 
mandate use of negotiated rulemaking to develop all regulations 
to implement the IHCIA. Negotiated rulemaking is very resource-
intensive for both Federal and non-Federal participants. It can 
be effective in appropriate circumstances, but may not be the 
most effective way to obtain necessary Indian provider input in 
the development of IHCIA rules and regulations in a given case.
    Additionally, while we appreciate the value of consultation 
with Tribes, we have concerns about the consultation 
requirements. The bills would require Tribal consultation prior 
to the Centers for Medicare & Medicaid Services (CMS) adopting 
any policy or regulation, as well as require all HHS agencies 
to consult with urban Indian organizations prior to taking any 
action, or approving any action of a State, that may affect 
such organizations or urban Indians. Such requirements appear 
to be broader than the existing Tribal consultation requirement 
and would be very difficult to administer, given the hundreds 
of regulations and policies potentially covered.
    We have similar concerns about the considerable indirect 
adverse impact of the proposed new extensive reporting 
requirements and other administrative burdens on IHS and CMS 
would divert limited resources from other activities. As IHS 
programs and both IHS and CMS administrative functions are 
funded by capped discretionary accounts, the imposition of 
additional administrative duties on IHS and CMS would have the 
practical effect of requiring cutbacks in current activities.
    As we continue our thorough review of this far-reaching, 
complex legislation, we may have further comments on other 
provisions, particularly in Title IV. However, we wish to 
reiterate our strong commitment to reauthorization and 
improvement of the Indian health care programs. We will be 
happy to work with the Committees, the National Tribal Steering 
Committee, and other representatives of the American Indian and 
Alaska Native communities to develop a bill fully acceptable to 
all stakeholders in these important programs.
    Mr. Chairman, this concludes my statement. Thank you for 
this opportunity to discuss the reauthorization of the Indian 
Health Care Improvement Act and other issues. We will be happy 
to answer any questions that you may have.

Statement of Steven B. Nesmith, Assistant Secretary, Congressional and 
   Intergovernmental Relations, U.S. Department of Housing and Urban 
                              Development


                              INTRODUCTION


    Mr. Chairman, Mr. Vice Chairman, and Members of the 
Committee, thank you for inviting me to provide comments on S. 
556, the Indian Health Care Improvement Act Reauthorization of 
2003.
    My name is Steven B. Nesmith, and I am the Assistant 
Secretary for Congressional and Intergovernmental Relations. As 
you know, Public and Indian Housing (PIH) is responsible for 
the management, operation and oversight of HUD's Native 
American programs. These programs are available to 560 
Federally-recognized and a limited number of state-recognized 
Indian tribes. We serve these tribes directly, or through 
tribally designated housing entities (TDHEs), by providing 
grants and loan guarantees designed to support affordable 
housing, community and economic development activities. Our 
tribal partners are diverse; they are located on Indian 
reservations, in Alaska Native Villages, and in other 
traditional Indian areas.
    In addition to those duties, PIH's jurisdiction encompasses 
the public housing program, which aids the nation's 3,000-plus 
public housing agencies in providing housing and housing-
related assistance to low-income families.
    It is a pleasure to appear before you, and I would like to 
express my appreciation for your continuing efforts to improve 
the housing conditions of American Indian and Alaska Native 
peoples. Much progress is being made and tribes are taking 
advantage of new opportunities to improve the housing 
conditions of the Native American families residing on Indian 
reservations, on trust or restricted Indian lands, and in 
Alaska Native Villages. This momentum needs to be sustained as 
we continue to work together toward creating a better living 
environment throughout Indian Country.


                                OVERVIEW


    At the outset, let me reaffirm the Department of Housing 
and Urban Development's support for the principle of 
government-to-government relations with Indian tribes. HUD is 
committed to honoring this fundamental precept in our work with 
American Indians and Alaska Natives.
    On behalf of Secretary Martinez, thank you for the 
opportunity to provide testimony on S. 556. The Department 
agrees that the Indian Health Service (IHS), a division of the 
Department of Health and Human Services, is vital to the well-
being of individual Indian families and the Native American 
community as a whole. Native Americans often have no other 
means to receive the health care assistance and related 
activities provided by IHS.
    HUD's Office of Native American Programs continues its 
ongoing dialog with IHS representatives to coordinate our 
activities in a manner that supports tribal sovereignty, self-
determination and self-governance. The Department also 
participates in a federal interagency task force on 
infrastructure with the IHS, Environmental Protection Agency, 
Bureau of Indian Affairs and Department of Agriculture. It is 
within this perspective that the following comments are offered 
on the bill.


               BACKGROUND ON HUD NATIVE AMERICAN PROGRAMS


    In 1996, the Native American Housing Assistance and Self-
Determination Act (25 U.S.C. 4101 et seq.) (NAHASDA) became 
law. NAHASDA changed the way in which housing and housing-
related assistance is provided to Native American families. 
Prior to the Act, Indian housing authorities and Indian tribes 
applied for a variety of competitive, categorical grant 
programs, usually with differing program eligibility and 
reporting requirements. NAHASDA created the Indian Housing 
Block Grant (IHBG) Program, which is a non-competitive formula 
grant made to an Indian tribe or its tribally designated 
housing entity (TDHE).
    Under the IHBG Program an Indian tribe or the TDHE submits 
to HUD a five-year and a one-year Indian Housing Plan (IHP). 
The IHP contains information about how the recipient will use 
its IHBG funds to engage in the six affordable housing 
activities authorized by NAHASDA. Once the IHP is found to be 
in compliance with statutory and regulatory requirements, the 
tribe or TDHE executes a grant agreement to receive its IHBG 
allocation.
    The IHBG formula is based on the housing needs of each 
tribe and the tribe/TDHE's ongoing operation and maintenance 
needs for the dwelling units previously developed under the 
Indian Housing Program authorized by the U.S. Housing Act of 
1937, as amended. The IHBG formula is calculated by dividing 
the total amount appropriated each fiscal year among the number 
of eligible grant recipients. Formula components and variables 
are weighted to ensure that the complexities and differences 
among tribes are taken into consideration. Each tribe's formula 
allocation reflects these factors.
    The NAHASDA regulations (24 CFR 1000.306) require that the 
IHBG formula be reviewed by calendar year 2003 for possible 
modification or revision. At present, the Department is engaged 
in negotiated rulemaking (neg-reg) with a 26-member committee 
comprised of a broad cross-section of tribal stakeholders. The 
first neg-reg session was held in April; additional monthly 
meetings are ongoing and scheduled through this September.


                      SPECIFIC COMMENTS ON S. 556


    Let me turn now to our specific comments on S. 556, the 
Indian Health Care Improvement Act Reauthorization of 2003.
    As you know, the Administration is actively reviewing S. 
556 and will provide you with specific details of our analysis 
very shortly. The Administration has not taken a position 
regarding the transfer of NAHASDA funds between HUD and HHS. We 
do, however, have concerns about transferring NAHASDA funds 
between Federal agencies when NAHASDA now provides for the 
direct distribution of IHBG funds to tribes and their TDHE's 
based on a formula negotiated between tribes and the 
Department.
    An affordable housing activity under the IHBG Program is 
``development,'' which includes infrastructure such as site 
improvements and the development of utilities and utilities 
services for housing. The provision of water and sanitation 
facilities is included within this category. Tribes or TDHEs 
may currently enter into agreements with IHS to provide these 
services, or they may choose another service provider. We 
believe this is in keeping with the policy of self-
determination that is articulated in NAHASDA.
    Since 1997, nearly $28 million has been transferred to IHS 
through TDHEs for offsite sanitation facilities. Tribes and 
TDHEs continue to make difficult budgetary and management 
decisions on how to prioritize their IHBGs, which is consistent 
with tribal self-determination and self-government.
    Let me assure the Committee that we will work with you, our 
Federal partners in HHS and other Federal agencies, tribes and 
their TDHEs to ensure that the housing infrastructure needs in 
Native American communities are met in the most efficient 
manner possible. We are, nevertheless, concerned about any 
provisions that might erode the self-determination now provided 
for in NAHASDA.
    Thank you for the opportunity to express our views on S. 
556.

  Statement of Tommy G. Thompson, Secretary, Department of Health and 
                             Human Services

    Good afternoon, Mr. Chairman, Senator Inouye and members of 
the Committee. I am honored to testify before you today on the 
important issue of reauthorization of the Indian Health Care 
Improvement Act (IHCIA). Accompanying me today is Dr. Charles 
Grim, Director of the Indian Health Service (IHS). This 
landmark legislation forms the backbone of the system through 
which numerous Federal health programs serve American Indians 
and Alaska Natives (AI/ANs) and encourages participation of 
eligible AI/ANs in these programs. Legislation pending before 
this Committee and over in the House has been given the highest 
degree of consideration by the Department. My staff has worked 
tirelessly to respond to this Committee's and the House 
Resource Committee's request for our views on H.R. 2440. I am 
pleased to share with you today the result of our efforts to 
improve services provided by the Indian Health Service, Tribes, 
Tribal Organizations, Alaska Native Villages and Urban Health 
Programs.
    As Secretary of the Department of Health and Human Services 
(HHS), it has been my goal to improve coordination to the 
maximum extent possible among the operating and staff divisions 
at the Department and to encourage collaboration between the 
Department and Tribes on the many programs impacting their 
members. As you know, upon my arrival at HHS, I reactivated the 
Intradepartmental Council on Native American Affairs (ICNAA) to 
provide a consistent HHS policy when working with the more than 
560 Federally recognized Tribes.
    I am also proud of the many achievements over that past 
three years in the areas of access, consultation, 
collaboration, organization, education, sanitation facilities 
construction and Medicare reform. And, I have traveled widely 
to Indian country over the past three years and visited with 
Tribes from the Chippewa Indians and Oglala Sioux Tribe, to 
Alaska Native Villages including Point Hope and Kwethluk. I 
just arrived back from a visit with the Navajo Nation and will 
return again to Alaska later this month to meet with Native 
leaders in Anchorage and representatives of Southeast Alaska 
Rural Health Consortium in Juneau. Through my travels, I have 
recognized the need for improvements in facilities that provide 
the base from which so many health care needs are met. In this 
area, I would like to work closely with Congress to continue to 
address this need.


                          HHS ACCOMPLISHMENTS


    The Department has improved Tribal access to HHS resources 
in both appropriated funding as well as to non-earmarked funds 
and increases in discretionary set asides. Between FY 2001 and 
FY 2003, HHS resources provided to Tribes or expended for the 
benefit of Tribes increased from $3.9 billion in 2001 to $4.4 
billion in 2003. This reflects an 11% increase in access to HHS 
funding for Tribes during just a two-year period.
    In response to Tribal leader comments at the regional 
Tribal consultation session, we have honored many requests 
including:
           Establishing a Center for Medicare and 
        Medicaid Services (CMS)--Technical Tribal Advisory 
        Group (TTAG), which held its first formal meeting at 
        the Department on February 10, 2004;
           Revising the existing HHS Tribal 
        consultation policy and involving Tribal leaders in 
        this process;
           Helping to bridge tribal/state relations for 
        HHS programs administered through States: HHS, the 
        National Congress of American Indians (NCAI) and the 
        American Public Human Services Association (APHSA) have 
        now entered into a Federal/State/Tribal collaborative 
        project to work together on health and human services 
        provided to Indian Tribes and Native organizations. HHS 
        is forming a workgroup to focus on key areas of 
        priorities identified by Tribes (TANF, Child Welfare, 
        Information Systems, etc.);
           Improving outcomes of Indian children and 
        families with Diabetes by increasing education and 
        physical activity programs; and,
           Recommending that funding be increased for 
        the IHS Sanitation Facilities Construction (SFC): The 
        President's FY 2005 Budget request for IHS includes an 
        increase of $10 million for SFC.
    Moreover, I am pleased that the Medicare Prescription Drug, 
Improvement, and Modernization Act of 2003 (MMA), passed by 
Congress last year, included two provisions identified by 
Indian health programs as high priorities. First, the MMA 
allows Indian health programs to use Medicare's bargaining 
power when purchasing care from Medicare participating 
hospitals for their non-Medicare patients, thus stretching 
contract health and Urban Indian health funding further. 
Second, the MMA allows IHS and Tribal hospitals and clinics to 
bill for additional Medicare Part B services for the period 
2005-2008. Finally, we are pleased that the MMA includes 
special provisions designed to help assure that pharmacies 
operated by Indian health programs, as well as other 
pharmacies, can participate in the temporary drug discount card 
and the permanent Part D drug benefit programs.


                         HHS VIEWS AND COMMENTS


    The Department is strongly committed to the reauthorization 
of the IHCIA during this Congress in order to improve the 
health status of American Indian people and to increase the 
availability of health services for them. We believe that 
reauthorizing legislation should provide increased flexibility 
to enable the Department to work with Tribes to improve the 
quality of health care for American Indian people, to better 
empower the Tribes to provide quality health, to increase the 
availability of health care, including new approaches to 
delivering care, and to expand the scope of health services 
available to eligible American Indians and Alaska Natives.
    Accordingly, I commend Congress for including in H.R. 2440 
various changes that respond to concerns raised in our 
September 27, 2001 bill report to the Senate Committee on 
Indian Affairs on S. 212, a similar IHCIA reauthorization bill 
in the 107th Congress. Moreover, I would like to note our 
particular interest in, and support for, certain provisions of 
H.R. 2440. I an impressed with the strengthening of provisions 
in all program areas including:
          (1) Improving recruitment and retention of qualified 
        providers, which are the foundation upon which all 
        services are provided by the IHS, Tribes and Tribal 
        Organizations and Urban Health Programs (ITUs);
          (2) Providing for improved health services to 
        eligible Indians;
          (3) Exempting Indians from cost sharing in the 
        Medicaid and SCHIP programs, consistent with our 
        current treatment of eligible Indian children under 
        SCHIP; and,
          (4) Expanding behavioral health programs to provide 
        for much needed prevention and treatment in the areas 
        of child sexual abuse, family violence, mental health, 
        and other problems.
    In addition, we believe that H.R. 2440, by proposing to 
protect eligible Indians from cost-sharing under the Medicaid 
and SCHIP programs, reflects the unique government-to-
government relationship of the United States to Federally-
recognized Indian Tribes. We would support such a proposal as 
consistent with current HHS policy to exempt eligible Indian 
children in SCHIP from premiums and cost-sharing. The proposed 
policy on cost-sharing would go far toward addressing the 
continuing underenrollment of eligible Indian individuals and 
families in Medicaid.
    In the area of behavioral health, H.R. 2440 provides for 
the needs of Indian women and youth and expands behavioral 
health services to include a much needed child sexual abuse and 
prevention treatment program. The Department supports this 
effort, but we recommend you permit the Secretary the 
flexibility to provide for these important programs in a manner 
that supports the local control and priorities of Tribes to 
address their specific need.
    The Department does have concerns about provisions 
affecting the Medicare statute. Given the magnitude of the 
changes and new programs required by the recently enacted MMA 
and the challenges in implementing these changes by the 
statutory deadlines, we do not believe it is feasible to make 
additional modifications to Medicare at this time. We also have 
concerns about provisions impacting the Medicare trust funds, 
which, as you know, face significant financial challenges in 
the future. Finally, we have several serious concerns about the 
impact of H.R. 2440 on the Medicaid and SCHIP programs. 
Specifically, we do not believe that requiring access to unused 
SCHIP allotments is appropriate because it would set a 
precedent within SCHIP of prioritizing a population that is 
already eligible for services under current law, within a fixed 
amount of funds.
    Additionally, the Department is concerned with several 
provisions included in the bill related to consultation 
requirements. H.R. 2440 proposes requirements for Federal 
agencies to consult with Federally-recognized Indian Tribes and 
Tribal organizations into statute. As exemplified by the 
successful outcomes of the Department's consultative process 
with the Tribes, the Administration remains strongly committed 
to consultation with Tribes as provided in Presidential 
Executive Order 13175. Furthermore, consultation with Tribes is 
provided for an the Indian Self-Determination and Education 
Assistance Act of 1975 (ISDEAA). We, therefore, recommend 
striking all language regarding consultation requirements.
    I reiterate our strong commitment to reauthorization and 
improvement of Indian health care programs, and I hope to work 
with this Committee and other Committees of the Congress, the 
National Tribal Steering Committee, and other representatives 
of Indian country to develop a bill that all stakeholders in 
these important programs can support. To this end, my staff 
will be communicating with your staff in the near future to 
share additional comments and suggestions regarding 
reauthorization.

                        Changes in Existing Law

    In compliance with subsection 12 of rule XXVI of the 
Standing Rules of the Senate, the Committee notes the following 
changes in existing law made by the bill, S. 556, as ordered 
reported, are shown as follows (existing law proposed to be 
omitted is enclosed in black brackets, new matter is printed in 
italic, existing law in which no change is proposed is shown in 
roman):

                      UNITED STATES CODE ANNOTATED

                           TITLE 25. INDIANS

                     CHAPTER 18--INDIAN HEALTH CARE


                           GENERAL PROVISIONS

Sec.
1. Short title; table of contents
1601. [Congressional f]Findings.
1602. Declaration of National Indian health [objectives] policy.
1603. Definitions.

 [SUBCHAPTER] TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT 
                        [PROFESSIONAL PERSONNEL]

1611. [Congressional statement of p]Purpose.
1612. Health [p]Professions [r]Recruitment [p]Program for Indians.
1613. Health [p]Professions [p]Preparatory [s]Scholarship [p]Program for 
          Indians.
1613a. Indian health professions scholarships.
105. American Indians into psychology program.
106. Funding for tribes for scholarship programs.
1614. Indian health service extern programs.
1615. Continuing education allowances.
1616. Community Health Representative Program.
1616a. Indian Health Service Loan Repayment Program.
1616a-1. Scholarship and [L]loan [R]repayment [R]recovery [F]fund.
1616b. Recruitment activities.
1616c. [Tribal] Indian recruitment and retention program.
1616d. Advanced training and research.
1616e. Quentin N. Burdick American Indians into [N]nursing program.
[1616e-1. Nursing school clinics.
[1616f. Tribal culture and history.]
1616g. I[NMED P]nmed program.
1616h. Health training programs of community colleges.
[1616i. Additional incentives for health professionals.]
1616j. Retention bonus.
1616k. Nursing residency program.
1616l. Community Health Aide Program for Alaska.
[1616m. Matching grants to tribes for scholarship programs.]
1616n. Tribal health program administration.
123. Health professional chronic shortage demonstration programs.
124. Treatment of scholarships for certain purposes.
125. National Health Service Corps.
126. Substance abuse counselor educational curricula demonstration 
          programs.
[1616o. University of South Dakota pilot program.]
1616p. Authorization of appropriations.

                 [SUBCHAPTER] TITLE II--HEALTH SERVICES

1621. Indian Health Care Improvement Fund.
1621a. Catastrophic [h]Health [e]Emergency [f]Fund.
1621b. Health promotion and disease prevention services.
1621c. Diabetes prevention, treatment, and control.
205. Shared services for long-term care.
[1621d. Hospice care feasibility study.
[1621e. Reimbursement from certain third parties of costs of health 
          services.
[1621f. Crediting of reimbursements.]
1621g. Health services research.
207. Mammography and other cancer screening.
[1621h. Mental health prevention and treatment services.
[1621i. Managed care feasibility study.
[1621j. California contract health services demonstration program.
[1621k. Coverage of screening mammography.]
1621l. Patient travel costs.
1621m. Epidemiology centers.
1621n. Comprehensive [school] health education programs.
1621o. Indian [y]Youth [grant] [p]Program.
[1621p. American Indians Into Psychology Program.]
1621q. Prevention, control, and elimination of [tuberculosis] 
          communicable and infectious diseases.
213. Authority for provision of other services.
214. Indian women's health care.
215. Environmental and nuclear health hazards.
216. Arizona as a contract health service delivery area.
216A. North Dakota as a contract health service delivery area.
216B. South Dakota as a contract health service delivery area.
217. California contract health services program.
218. California as a contract health service delivery area.
219. Contract health services for the Trenton Service Area.
220. Programs operated by Indian Tribes and Tribal Organizations.
221. Licensing or certification.
222. Notification of provision of emergency contract health services.
223. Prompt action on payment of claims.
[1621r. Contract health services payment study.
[1621s. Prompt action on payment of claims.
[1621t. Demonstration of electronic claims processing.]
1621u. Liability for payment.
[1621v. Office of Indian Women's Health Care.]
1621w. Authorization of appropriations.
[1621x. Limitation on use of funds.
[1622. Transferred.]

               [SUBCHAPTER] TITLE III--[HEALTH] FACILITIES

1631. Consultation; [closure] construction and renovation of facilities; 
          reports.
1632. [Safe water and sanitary waste disposal] Sanitation facilities.
1633. Preference to Indians and Indian firms.
1634. Expenditure of [non-Service] nonservice funds for renovation.
[1635. Repealed.]
1636. [Grant program] Funding for the construction, expansion, and 
          modernization of small ambulatory care facilities.
1637. Indian [h]Health [c]Care [d]Delivery [d]Demonstration [p]Project.
1638. Land transfer.
308. Leases, contracts, and other agreements.
309. Study on loans, loan guarantees, and loan repayment.
310. Tribal leasing.
311. Indian Health Service/tribal facilities joint venture program.
312. Location of facilities.
313. Maintenance and improvement of health care facilities.
314. Tribal management of federally owned quarters.
[1638a. Authorization of appropriations.]
1638b. Applicability of Buy American requirement.
316. Other funding for facilities.
317. Authorization of appropriations.
[1638c. Contracts for personal services in Indian Health Service 
          facilities.
[1638d. Credit to appropriations of money collected for meals at Indian 
          Health Service facilities.]

         [SUBCHAPTER III-A] TITLE IV--ACCESS TO HEALTH SERVICES

1641. Treatment of payments under [medicare program] Social Security Act 
          health care programs.
[1642. Treatment of payments under medicaid program.
[1643. Amount and use of funds reimbursed through medicare and medicaid 
          available to Indian Health Service.]
1644. Grants to and [contracts] funding agreements with the Service, 
          Indian Tribes, [t]Tribal [o]Organizations, and Urban Indian 
          organizations.
403. Reimbursement from certain third parties of costs of health 
          services.
404. Crediting of reimbursements.
405. Purchasing health care coverage.
406. Sharing arrangements with Federal agencies.
407. Payor of last resort.
408. Nondiscrimination in qualifications for reimbursement for services.
409. Consultation.
410. State children's health insurance program (SCHIP).
411. Social Security Act sanctions.
412. Cost sharing.
413. Treatment under medicaid managed care.
414. Navajo nation medicaid agency feasibility study.
[1645. Direct billing of Medicare, Medicaid, and other third party 
          payors.
[1646. Authorization for emergency contract health services.]
1647. Authorization of appropriations.

       [SUBCHAPTER IV] TITLE V--HEALTH SERVICES FOR URBAN INDIANS

1651. Purpose.
1652. Contracts with, and grants to, [u]Urban Indian [o]Organizations.
1653. Contracts and grants for the provision of health care and referral 
          services.
1654. Contracts and grants for the determination of unmet health care 
          needs.
1655. Evaluations; renewals.
1656. Other contract and grant requirements.
1657. Reports and records.
1658. Limitation on contract authority.
1659. Facilities [renovation].
1660. Office of Urban Indian Health [Programs Branch].
1660a. Grants for alcohol and substance abuse-related services.
1660b. Treatment of certain demonstration projects.
1660c. Urban NIAAA transferred programs.
514. Consultation with Urban Indian Organizations.
515. Federal Tort Claims Act coverage.
516. Urban youth treatment center demonstration.
517. Use of Federal property and supplies.
518. Grants for diabetes prevention, treatment, and control.
519. Community health representatives.
520. Regulations.
521. Eligibility for services.
1660d. Authorization of appropriations.

          [SUBCHAPTER V] TITLE VI--ORGANIZATIONAL IMPROVEMENTS

1661. Establishment of Indian Health Service as an agency of Public 
          Health Service.
1662. Automated management information system.
1663. Authorization of appropriations.

 [SUBCHAPTER V-A--SUBSTANCE ABUSE] TITLE VII--BEHAVIORAL HEALTH PROGRAMS

[1665. Indian Health Service responsibilities.
[1665a. Indian Health Service program.]
701. Behavioral health prevention and treatment services.
702. Memoranda of agreement with the Department of the Interior.
703. Comprehensive behavioral health prevention and treatment program.
704. Mental health technician program.
705. Licensing requirement for mental health care workers.
1665b. Indian women treatment programs.
1665c. Indian [Health Service y]Youth [p]Program.
708. Inpatient and community-based mental health facilities design, 
          construction, and staffing.
1665d. Training and community education.
[1665e. Gallup alcohol and substance abuse treatment center.]
[1665f. Reports.]
710. Behavioral health program.
1665g. Fetal alcohol [syndrome and fetal alcohol effect grants] disorder 
          funding.
[1665h. Pueblo substance abuse treatment project for San Juan Pueblo, 
          New Mexico.
[1665i. Thunder Child Treatment Center.
[1665j. Substance abuse counselor education demonstration project.
[1665k. Gila River alcohol and substance abuse treatment facility.
[1665l. Alaska Native drug and alcohol abuse demonstration project.]
712. Child sexual abuse and prevention treatment programs.
713. Behavioral health research.
714. Definitions.
1665m. Authorization of appropriations.

                [SUBCHAPTER VI] TITLE VIII--MISCELLANEOUS

1671. Reports.
1672. Regulations.
[1673. Repealed.]
[1674. Leases with Indian tribes.]
803. Plan of implementation.
1675. Availability of funds.
1676. Limitation on use of funds appropriated to the Indian Health 
          Service.
[1677. Nuclear resource development health hazards.
[1678. Arizona as a contract health service delivery area.]
1679. Eligibility of California Indians.
[1680. California as a contract health service delivery area.
[1680a. Contract health facilities.
[1680b. National Health Service Corps.]
1680c. Health services for ineligible persons.
[1680d. Infant and maternal mortality; fetal alcohol syndrome.
[1680e. Contract health services for the Trenton Service Area.
[1680f. Indian Health Service and Department of Veterans Affairs health 
          facilities and services sharing.]
1680g. Reallocation of base resources.
[1680h. Demonstration projects for tribal management of health care 
          services.
[1680i. Child sexual abuse treatment programs.
[1680j. Tribal leasing.
[1680k. Home- and community-based care demonstration project.
[1680l. Shared services demonstration project.]
1680m. Results of demonstration projects.
810. Provision of services in Montana.
811. Moratorium.
812. Tribal employment.
813. Prime vendor.
814. Severability provisions
815. Establishment of National Bipartisan Commission on Indian Health 
          Care Entitlement.
816. Appropriations; availability.
817. Confidentiality of medical quality assurance records: qualified 
          immunity for participants.
[1680n. Priority for Indian reservations.]
1680o. Authorization of appropriations.
[1681. Omitted.
[1682. Subrogation of claims by Indian Health Service.
[1683. Indian Catastrophic Health Emergency Fund.]

                           GENERAL PROVISIONS


Sec. 1601. [Congressional f]Findings

    [The] Congress finds the following:
    [(a)] (1) Federal delivery of health services and funding 
of Indian and Urban Indian Health Programs to maintain and 
improve the health of [the] Indians are consonant with and 
required by the Federal Government's historical and unique 
legal relationship with Indians, as reflected in the 
Constitution, treaties, Federal statutes and the course of 
dealings of the United States with Indian Tribes and the United 
States' [and] resulting government-to-government relationship 
with Indian Tribes and trust responsibilit[y]ies and 
obligations to[, the American] Indians [people].
    (2) From the time of European occupation and colonization 
through the 20th century, policies and practices of the United 
States caused and/or contributed to the severe health 
conditions of Indians.
    (3) Through the cession of over 400,000,000 acres of land 
to the United States in exchange for promises, often reflected 
in treaties, of health care, Indian Tribes have secured a de 
facto contract which entitles Indians to health care in 
perpetuity, based on the moral, legal, and historic obligation 
of the United States.
    (4) The population growth of Indians that began in the 
later part of the 20th century increases the need for Federal 
health care services.
    [(b)] (5) A major national goal of the United States is to 
provide the quantity and quality of health services which will 
permit the health status of Indians regardless of where they 
live to be raised to the highest possible level that is no less 
than that of the general population and to [encourage] provide 
for the maximum participation of Indian[s] Tribes, Tribal 
Organizations, and Urban Indian Organizations in the planning, 
delivery and management of those health services.
    [(c)] (6) Federal health services to Indians have resulted 
in a reduction in the prevalence and incidence of [preventable] 
illnesses among, and unnecessary and premature deaths of, 
Indians.
    [(d)] (7) Despite such services, the unmet health needs of 
[the American] Indians [people are] remain alarmingly severe 
and the health status of [the] Indians is far below the health 
status [that] of the general population of the United States.
    (8) The disparity to be addressed is formidable. For 
example, Indians suffer a death rate for diabetes mellitus that 
is 318 percent higher than the all races rate for the United 
States, a pneumonia and influenza death rate 52 percent 
greater, a tuberculosis death rate that is 650 percent greater, 
and a death rate from alcoholism that is 670 percent higher 
than that of the all races United States rate.

Sec. 1602. Declaration of [health objectives] National Indian Health 
                    Policy

    [(a) The] Congress hereby declares that it is the policy of 
this Nation, in fulfillment of its special trust 
responsibilities and legal obligations to [the American] 
Indians--[people,]
          (1) to assure the highest possible health status for 
        Indians [and urban Indians] and to provide all 
        resources necessary to effect that policy[.];
    [(b) It is the intent of the Congress that the Nation meet 
the following health status objectives with respect to Indians 
and urban Indians by the year 2000:
          [(1) Reduce coronary heart disease deaths to a level 
        of no more than 100 per 100,000.
          [(2) Reduce the prevalence of overweight individuals 
        to no more than 30 percent.
          [(3) Reduce the prevalence of anemia to less than 10 
        percent among children aged 1 through 5.
          [(4) Reduce the level of cancer deaths to a rate of 
        no more than 130 per 100,000.
          [(5) Reduce the level of lung cancer deaths to a rate 
        of nomore than 42 per 100,000.
          [(6) Reduce the level of chronic obstructive 
        pulmonary disease related deaths to a rate of no more 
        than 25 per 100,000.
          [(7) Reduce deaths among men caused by alcohol-
        related motor vehicle crashes to no more than 44.8 per 
        100,000.
          [(8) Reduce cirrhosis deaths to no more than 13 per 
        100,000.
          [(9) Reduce drug-related deaths to no more than 3 per 
        100,000.
          [(10) Reduce pregnancies among girls aged 17 and 
        younger to no more than 50 per 1,000 adolescents.
          [(11) Reduce suicide among men to no more than 12.8 
        per 100,000.
          [(12) Reduce by 15 percent the incidence of injurious 
        suicide attempts among adolescents aged 14 through 17.
          [(13) Reduce to less than 10 percent the prevalence 
        of mental disorders among children and adolescents.
          [(14) Reduce the incidence of child abuse or neglect 
        to less than 25.2 per 1,000 children under age 18.
          [(15) Reduce physical abuse directed at women by male 
        partners to no more than 27 per 1,000 couples.
          [(16) Increase years of healthy life to at least 65 
        years.
          [(17) Reduce deaths caused by unintentional injuries 
        to no more than 66.1 per 100,000.
          [(18) Reduce deaths caused by motor vehicle crashes 
        to no more than 39.2 per 100,000.
          [(19) Among children aged 6 months through 5 years, 
        reduce the prevalence of blood lead levels exceeding 15 
        ug/dl and reduce to zero the prevalence of blood lead 
        levels exceeding 25 ug/dl.
          [(20) Reduce dental caries (cavities) so that the 
        proportion of children with one or more caries (in 
        permanent or primary teeth) is no more than 45 percent 
        among children aged 6 through 8 and no more than 60 
        percent among adolescents aged 15.
          [(21) Reduce untreated dental caries so that the 
        proportion of children with untreated caries (in 
        permanent or primary teeth) is no more than 20 percent 
        among children aged 6 through 8 and no more than 40 
        percent among adolescents aged 15.
          [(22) Reduce to no more than 20 percent the 
        proportion of individuals aged 65 and older who have 
        lost all of their natural teeth.
          [(23) Increase to at least 45 percent the proportion 
        of individuals aged 35 to 44 who have never lost a 
        permanent tooth due to the dental caries or periodontal 
        disease.
          [(24) Reduce destructive periodontal disease to a 
        prevalence of no more than 15 percent among individuals 
        aged 35 to 44.
          [(25) Increase to at least 50 percent the proportion 
        of children who have received protective sealants on 
        the occlusal (chewing) surfaces of permanent molar 
        teeth.
          [(26) Reduce the prevalence of gingivitis among 
        individuals aged 35 to 44 to no more than 50 percent.
          [(27) Reduce the infant mortality rate to no more 
        than 8.5 per 1,000 live births.
          [(28) Reduce the fetal death rate (20 or more weeks 
        of gestation) to no more than 4 per 1,000 live births 
        plus fetal deaths.
          [(29) Reduce the maternal mortality rate to no more 
        than 3.3 per 100,000 live births.
          [(30) Reduce the incidence of fetal alcohol syndrome 
        to no more than 2 per 1,000 live births.
          [(31) Reduce stroke deaths to no more than 20 per 
        100,000.
          [(32) Reverse the increase in end-stage renal disease 
        (requiring maintenance dialysis or transplantation) to 
        attain an incidence of no more than 13 per 100,000.
          [(33) Reduce breast cancer deaths to no more than 
        20.6 per 100,000 women.
          [(34) Reduce deaths from cancer of the uterine cervix 
        to no more than 1.3 per 100,000 women.
          [(35) Reduce colorectal cancer death to no more than 
        13.2 per 100,000.
          [(36) Reduce to no more than 11 percent the 
        proportion of individuals who experience a limitation 
        in major activity due to chronic conditions.
          [(37) Reduce significant hearing impairment to a 
        prevalence of no more than 82 per 1,000.
          [(38) Reduce significant visual impairment to a 
        prevalence of no more than 30 per 1,000.
          [(39) Reduce diabetes-related deaths to no more than 
        48 per 100,000.
          [(40) Reduce diabetes to an incidence of no more than 
        2.5 per 1,000 and a prevalence of no more than 62 per 
        1,000.
          [(41) Reduce the most severe complications of 
        diabetes as follows:
                  [(A) End-stage renal disease, 1.9 per 1,000.
                  [(B) Blindness, 1.4 per 1,000.
                  [(C) Lower extremity amputation, 4.9 per 
                1,000.
                  [(D) Perinatal mortality, 2 percent.
                  [(E) Major congenital malformations, 4 
                percent.
          [(42) Confine annual incidence of diagnosed AIDS 
        cases to no more than 1,000 cases.
          [(43) Confine the prevalence of HIV infection to no 
        more than 100 per 100,000.
          [(44) Reduce gonorrhea to an incidence of no more 
        than 225 cases per 100,000.
          [(45) Reduce chlamydia trachomatis infections, as 
        measured by a decrease in the incidence of 
        nongonococcal urethritis to no more than 170 cases per 
        100,000.
          [(46) Reduce primary and secondary syphilis to an 
        incidence to no more than 10 cases per 100,000.
          [(47) Reduce the incidence of pelvic inflammatory 
        disease, as measured by a reduction in hospitalization 
        for pelvic inflammatory disease to no more than 250 per 
        100,000 women aged 15 through 44.
          [(48) Reduce viral hepatitis B infection to no more 
        than 40 per 100,000 cases.
          [(49) Reduce indigenous cases of vaccine-preventable 
        diseases as follows:
                  [(A) Diphtheria among individuals aged 25 and 
                younger, 0.
                  [(B) Tetanus among individuals aged 25 and 
                younger, 0.
                  [(C) Polio (wild-type virus), 0.
                  [(D) Measles, 0.
                  [(E) Rubella, 0.
                  [(F) Congenital Rubella Syndrome, 0.
                  [(G) Mumps, 500.
                  [(H) Pertussis, 1,000.
          [(50) Reduce epidemic-related pneumonia and influenza 
        deaths among individuals aged 65 and older to no more 
        than 7.3 per 100,000.
          [(51) Reduce the number of new carriers of viral 
        hepatitis B among Alaska Natives to no more than 1 
        case.
          [(52) Reduce tuberculosis to an incidence of no more 
        than 5 cases per 100,000.
          [(53) Reduce bacterial meningitis to no more than 8 
        cases per 100,000.
          [(54) Reduce infectious diarrhea by at least 25 
        percent among children.
          [(55) Reduce acute middle ear infections among 
        children aged 4 and younger, as measured by days of 
        restricted activity or school absenteeism, to no more 
        than 105 days per 100 children.
          [(56) Reduce cigarette smoking to a prevalence of no 
        more than 20 percent.
          [(57) Reduce smokeless tobacco use by youth to a 
        prevalence of no more than 10 percent.
          [(58) Increase to at least 65 percent the proportion 
        ofparents and caregivers who use feeding practices that 
prevent baby bottle tooth decay.
          [(59) Increase to at least 75 percent the proportion 
        of mothers who breast feed their babies in the early 
        postpartum period, and to at least 50 percent the 
        proportion who continue breast feeding until their 
        babies are 5 to 6 months old.
          [(60) Increase to at least 90 percent the proportion 
        of pregnant women who receive prenatal care in the 
        first trimester of pregnancy.
          [(61) Increase to at least 70 percent the proportion 
        of individuals who have received, as a minimum within 
        the appropriate interval, all of the screening and 
        immunization services and at least one of the 
        counseling services appropriate for their age and 
        gender as recommended by the United States Preventive 
        Services Task Force.
    [(c) It is the intent of the Congress that the Nation 
increase the proportion of all degrees in the health 
professions and allied and associated health profession fields 
awarded to Indians to 0.6 percent.
    [(d) The Secretary shall submit to the President, for 
inclusion in each report required to be transmitted to the 
Congress under section 1671 of this title, a report on the 
progress made in each area of the Service toward meeting each 
of the objectives described in subsection (b) of this section.]
          (2) to raise the health status of Indians by the year 
        2010 to at least the levels set forth in the goals 
        contained within the Healthy People 2010 or successor 
        objectives;
          (3) to the greatest extent possible, to allow Indians 
        to set their own health care priorities and establish 
        goals that reflect their unmet needs;
          (4) to increase the proportion of all degrees in the 
        health professions and allied and associated health 
        professions awarded to Indians so that the proportion 
        of Indian health professionals in each Service Area is 
        raised to at least the level of that of the general 
        population;
          (5) to require meaningful consultation with Indian 
        Tribes, Tribal Organizations, and Urban Indian 
        Organizations to implement this Act and the national 
        policy of Indian self-determination; and
          (6) to provide funding for programs and facilities 
        operated by Indian Tribes and Tribal Organizations in 
        amounts that are not less than the amounts provided to 
        programs and facilities operated directly by the 
        Service.

Sec. 1603. Definitions

    For purposes of this [chapter] Act[--]:
          (1) The term `accredited and accessible' means on or 
        near a reservation and accredited by a national or 
        regional organization with accrediting authority.
          (2) The term `Area Office' means an administrative 
        entity including a program office, within the Service 
        through which services and funds are provided to the 
        Service Units within a defined geographic area.
          (3) The term `Assistant Secretary' means the 
        Assistant Secretary of Indian Health.
          (4) The term `behavioral health' means the blending 
        of substance (alcohol, drugs, inhalants, and tobacco) 
        abuse and mental illness prevention and treatment, for 
        the purpose of providing comprehensive services. This 
        definition can include the joint development of 
        substance abuse and mental illness treatment planning 
        and coordinated case management using a 
        multidisciplinary approach.
          (5) The term `California Indians' shall mean those 
        Indians who are eligible for health services of the 
        Service pursuant to section 806.
          (6) The term `community college' means--
                  (A) a tribal college or university, or
                  (B) a junior or community college.
          (7) The term `contract health service' means health 
        services provided at the expense of the Service or a 
        Tribal Health Program by public or private medical 
        providers or hospitals, other than the Service Unit or 
        the Tribal Health Program at whose expense the services 
        are provided.
          (8) The term `Department' means, unless otherwise 
        designated, the Department of Health and Human 
        Services.
          (9) The term `disease prevention' means the 
        reduction,limitation, and prevention of disease and its 
complications and reduction in the consequences of disease, including--
                  (A) controlling--
                          (i) development of diabetes;
                          (ii) high blood pressure;
                          (iii) infectious agents;
                          (iv) injuries;
                          (v) occupational hazards and 
                        disabilities;
                          (vi) sexually transmittable diseases; 
                        and
                          (vii) toxic agents; and
                  (B) providing--
                          (i) fluoridation of water; and
                          (ii) immunizations.
          (10) The term `fund' or `funding' means the transfer 
        of moneys from the Department to any eligible entity or 
        individual under this Act by any legal means, including 
        Funding Agreements, contracts, grants, memoranda of 
        understanding, contracts pursuant to section 23 of the 
        Act of April 20, 1908 (25 U.S.C. 47; commonly known as 
        the `Buy Indian Act'), or otherwise. Any program 
        administered as a grant program one day before the date 
        of enactment may continue to be administered as a grant 
        program. This definition does not otherwise modify 
        grant programs, except that upon request of the Indian 
        Tribes or Tribal Organizations, discretionary grants 
        and all categories of awarded nonrecurring funding 
        shall be included in the Funding Agreement. 
        Discretionary grant funds shall be governed by all the 
        particular terms and conditions attached to such funds, 
        unless waived by the Secretary. All particular terms 
        and conditions attached to the discretionary grant 
        funds must be shown in the Funding Agreement. The use 
        of such grant funds shall be governed by the terms and 
        conditions set forth in the Funding Agreement and not 
        the substantive provisions of the Indian Self-
        Determination and Education Assistance Act (25 U.S.C. 
        450 et seq.).
          (11) The term `Funding Agreement' means any agreement 
        to transfer funds for the planning, conduct, and 
        administration of programs, services, functions, and 
        activities to Indian Tribes and Tribal Organizations 
        from the Secretary under the Indian Self-Determination 
        and Education Assistance Act (25 U.S.C. 450 et seq.).
          (12) The term `health profession' means allopathic 
        medicine, family medicine, internal medicine, 
        pediatrics, geriatric medicine, obstetrics and 
        gynecology, podiatric medicine, nursing, public health 
        nursing, advanced practice nursing, dentistry, 
        psychiatry, osteopathy, optometry, pharmacy, 
        psychology, public health, social work, marriage and 
        family therapy, chiropractic medicine, environmental 
        health and engineering, allied health professions, and 
        any other health profession.
          (13) The term `health promotion' means--
                  (A) fostering social, economic, 
                environmental, and personal factors conducive 
                to health, including raising public awareness 
                about health matters and enabling the people to 
                cope with health problems by increasing their 
                knowledge and providing them with valid 
                information;
                  (B) encouraging adequate and appropriate 
                diet, exercise, and sleep;
                  (C) promoting education and work in 
                conformity with physical and mental capacity;
                  (D) making available suitable housing, safe 
                water, and sanitary facilities;
                  (E) improving the physical, economic, 
                cultural, psychological, and social 
                environment;
                  (F) promoting adequate opportunity for 
                spiritual, religious, and Traditional Health 
                Care Practices; and
                  (G) providing adequate and appropriate 
                programs, including, but not limited to--
                          (i) abuse prevention (mental and 
                        physical);
                          (ii) community health;
                          (iii) community safety;
                          (iv) consumer health education;
                          (v) diet and nutrition;
                          (vi) immunization and other 
                        prevention of communicable diseases, 
                        including HIV/AIDS;
                          (vii) environmental health;
                          (viii) exercise and physical fitness;
                          (ix) avoidance of fetal alcohol 
                        disorders;
                          (x) first aid and CPR education;
                          (xi) human growth and development;
                          (xii) injury prevention and personal 
                        safety;
                          (xiii) behavioral health;
                          (xiv) monitoring of disease 
                        indicators between health care provider 
                        visits, through appropriate means, 
                        including Internet-based health care 
                        management systems;
                          (xv) personal health and wellness 
                        practices;
                          (xvi) personal capacity building;
                          (xvii) prenatal, pregnancy, and 
                        infant care;
                          (xviii) psychological well-being;
                          (xix) reproductive health and family 
                        planning;
                          (xx) safe and adequate water;
                          (xxi) safe housing relative to 
                        eliminating, reducing, or preventing 
                        contaminants which create unhealthy 
                        housing conditions;
                          (xxii) safe work environments;
                          (xxiii) stress control;
                          (xxiv) substance abuse;
                          (xxv) sanitary facilities;
                          (xxvi) sudden infant death syndrome 
                        prevention;
                          (xxvii) tobacco use cessation and 
                        reduction;
                          (xxviii) violence prevention; and
                          (xxix) such other activities 
                        identified by the Service, a Tribal 
                        Health Program, or an Urban Indian 
                        Organization, to promote achievement of 
                        any of the objectives described in 
                        section 3(2).
          (14) The term `Indian' has the meaning given the term 
        in the Indian Self-Determination and Education 
        Assistance Act (25 U.S.C. 450 et seq.).
          (15) The term `Indian Health Program' means--
                  (A) any health program administered directly 
                by the Service;
                  (B) any Tribal Health Program; or
                  (C) any Indian Tribe or Tribal Organization 
                to which the Secretary provides funding 
                pursuant to section 23 of the Act of April 30, 
                1908 (25 U.S.C. 47), commonly known as the `Buy 
                Indian Act'.
          (16) The term `Indian Tribe' has the meaning given 
        the term in the Indian Self-Determination and Education 
        Assistance Act (25 U.S.C. 450 et seq.).
          (17) The term `junior or community college' has the 
        meaning given the term by section 312(e) of the Higher 
        Education Act of 1965 (20 U.S.C. 1058(e)).
          (18) The term `reservation' means any federally 
        recognized Indian Tribe's reservation, Pueblo, or 
        colony, including former reservations in Oklahoma, 
        Indian allotments, and Alaska Native Regions 
        established pursuant to the Alaska Native Claims 
        Settlement Act (25 U.S.C. 1601 et seq.).
          [(a)] (19) The term [``]`Secretary['']', unless 
        otherwise designated, means the Secretary of Health and 
        Human Services.
          [(b)] (20) The term [``]`Service['']' means the 
        Indian Health Service.
    [(c) ``Indians'' or ``Indian'', unless otherwise 
designated, means any person who is a member of an Indian 
tribe, as defined in subsection (d) of this section, except 
that, for the purpose of sections 1612 and 1613 of this title, 
such terms shall mean any individual who (1), irrespective of 
whether he or she lives on or near a reservation, is a member 
of a tribe, band, or otherorganized group of Indians, including 
those tribes, bands, or groups terminated since 1940 and those 
recognized now or in the future by the State in which they reside, or 
who is a descendant, in the first or second degree, of any such member, 
or (2) is an Eskimo or Aleut or other Alaska Native, or (3) is 
considered by the Secretary of the Interior to be an Indian for any 
purpose, or (4) is determined to be an Indian under regulations 
promulgated by the Secretary.
    [(d) ``Indian tribe'' means any Indian tribe, band, nation, 
or other organized group or community, including any Alaska 
Native village or group or regional or village corporation as 
defined in or established pursuant to the Alaska Native Claims 
Settlement Act (85 Stat. 688) [43 U.S.C.A. Sec. 1601 et seq.], 
which is recognized as eligible for the special programs and 
services provided by the United States to Indians because of 
their status as Indians.
    [(e) ``Tribal organization'' means the elected governing 
body of any Indian tribe or any legally established 
organization of Indians which is controlled by one or more such 
bodies or by a board of directors elected or selected by one or 
more such bodies (or elected by the Indian population to be 
served by such organization) and which includes the maximum 
participation of Indians in all phases of its activities.]
          (21) The term `Service Area' means the geographical 
        area served by each Area Office.
          (22) The term `Service Unit' means an administrative 
        entity of the Service, or a Tribal Health Program 
        through which services are provided, directly or by 
        contract, to eligible Indians within a defined 
        geographic area.
          (23) The term `telehealth' has the meaning given the 
        term in section 330K(a) of the Public Health Service 
        Act (42 U.S.C. 254c-16(a)).
          (24) The term `telemedicine' means a 
        telecommunications link to an end user through the use 
        of eligible equipment that electronically links health 
        professionals or patients and health professionals at 
        separate sites in order to exchange health care 
        information in audio, video, graphic, or other format 
        for the purpose of providing improved health care 
        services.
          (25) The term `Traditional Health Care Practices' 
        means the application by Native healing practitioners 
        of the Native healing sciences (as opposed or in 
        contradistinction to Western healing sciences) which 
        embody the influences or forces of innate Tribal 
        discovery, history, description, explanation and 
        knowledge of the states of wellness and illness and 
        which call upon these influences or forces, including 
        physical, mental, and spiritual forces in the 
        promotion, restoration, preservation, and maintenance 
        of health, well-being, and life's harmony.
          (26) The term `tribal college or university' has the 
        meaning given the term in section 316(b)(3) of the 
        Higher Education Act (20 U.S.C. 1059c(b)(3)).
          (27) The term `Tribal Health Program' means an Indian 
        Tribe or Tribal Organization that operates any health 
        program, service, function, activity, or facility 
        funded, in whole or part, by the Service through, or 
        provided for in, a Funding Agreement with the Service 
        under the Indian Self-Determination and Education 
        Assistance Act (25 U.S.C. 450 et seq.).
          (28) The term `Tribal Organization' has the meaning 
        given the term in the Indian Self-Determination and 
        Education Assistance Act (25 U.S.C. 450 et seq.).
          (29) The term `Urban Center' means any community 
        which has a sufficient Urban Indian population with 
        unmet health needs to warrant assistance under title V 
        of this Act, as determined by the Secretary.
          [(f) ``] (30) The term `Urban Indian['']' means any 
        individual who resides in an [u]Urban [c]Center[, as 
        defined in subsection (g) of this section,] and who 
        meets [one] 1 or more of the [four] following criteria: 
        [ in subsection (c)(1) though (4) of this section.]
                  (A) Irrespective of whether the individual 
                lives on or near a reservation, the individual 
                is a member of a tribe, band, or other 
                organized group of Indians, including those 
                tribes, bands, or groups terminated since 1940 
                and those tribes, bands, or groups that are 
                recognized by the States in which they reside, 
                or who is a descendant in the first or second 
                degree of any such member.
                  (B) The individual is an Eskimo, Aleut, or 
                other Alaskan Native.
                  (C) The individual is considered by the 
                Secretary of the Interior to be an Indian for 
                any purpose.
                  (D) The individual is determined to be an 
                Indian under regulations promulgated by the 
                Secretary.
          (31) The term `Urban Indian Organization' means a 
        nonprofit corporate body that (A) is situated in an 
        Urban Center; (B) is governed by an Urban Indian-
        controlled board of directors; (C) provides for the 
        participation of all interested Indian groups and 
        individuals; and (D) is capable of legally cooperating 
        with other public and private entities for the purpose 
        of performing the activities described in section 
        503(a).
    [(g) ``Urban center'' means any community which has a 
sufficient urban Indian population with unmet health needs to 
warrant assistance under subchapter IV of this chapter, as 
determined by the Secretary.
    [(h) ``Urban Indian organization'' means a nonprofit 
corporate body situated in an urban center, governed by an 
urban Indian controlled board of directors, and providing for 
the maximum participation of all interested Indian groups and 
individuals, which body is capable of legally cooperating with 
other public and private entities for the purpose of performing 
the activities described in section 1653(a) of this title.
    [(i) ``Area office'' means an administrative entity 
including a program office, within the Indian Health Service 
through which services and funds are provided to the service 
units within a defined geographic area.
    [(j) ``Service unit'' means--
          [(1) an administrative entity within the Indian 
        Health Service, or]
          [(2) a tribe or tribal organization operating health 
        care programs or facilities with funds from the Service 
        under the Indian Self-Determination Act [25 U.S.C.A. 
        Sec. 450f et seq.],
through which services are provided, directly or by contract, 
to the eligible Indian population within a defined geographic 
area.
    [(k) ``Health promotion'' includes--
          [(1) cessation of tobacco smoking,
          [(2) reduction in the misuse of alcohol and drugs,
          [(3) improvement of nutrition,
          [(4) improvement in physical fitness,
          [(5) family planning,
          [(6) control of stress, and
          [(7) pregnancy and infant care (including prevention 
        of fetal alcohol syndrome).
    [(l) ``Disease prevention'' includes--
          [(1) immunizations,
          [(2) control of high blood pressure,
          [(3) control of sexually transmittable diseases,
          [(4) prevention and control of diabetes,
          [(5) control of toxic agents,
          [(6) occupational safety and health,
          [(7) accident prevention,
          [(8) fluoridation of water, and
          [(9) control of infectious agents.
    [(m) ``Service area'' means the geographical area served by 
each area office.
    [(n) ``Health profession'' means allopathic medicine, 
family medicine, internal medicine, pediatrics, geriatric 
medicine, obstetrics and gynecology, podiatric medicine, 
nursing, public health nursing, dentistry, psychiatry, 
osteopathy, optometry, pharmacy, psychology, public health, 
social work, marriage and family therapy, chiropractic 
medicine, environmental health and engineering, an allied 
health profession, or any other health profession.
    [(o) ``Substance abuse'' includes inhalant abuse.
    [(p) ``FAE'' means fetal alcohol effect.
    [(q) ``FAS'' means fetal alcohol syndrome.]

 [SUBCHAPTER] TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT 
                        [PROFESSIONAL PERSONNEL]

Sec. 1611. [Congressional statement of p]Purpose

    The purpose of this [subchapter] title is to increase, to 
the maximum extent feasible, the number of Indians entering the 
health professions and providing health services, and to assure 
an [adequate] optimum supply of health professionals to the 
Indian Health Programs [Service, Indian tribes, tribal 
organizations,] and [u]Urban Indian [o]Organizations involved 
in the provision of health care to Indians [people].

Sec. 1612. Health P[p]rofessions R[r]ecruitment P[p]rogram for Indians

    (a) [Grants for Education and Training] In General.--
    The Secretary, acting through the Service, shall make 
[grants] funds available to public or nonprofit private health 
or educational entities, Tribal Health Programs, or Urban 
Indian Organizations [or Indian tribes or tribal organizations] 
to assist such entities in meeting the costs of--
          (1) identifying Indians with a potential for 
        education or training in the health professions and 
        encouraging and assisting them--
                  (A) to enroll in courses of study in such 
                health professions; or
                  (B) if they are not qualified to enroll in 
                any such courses of study, to undertake such 
                postsecondary education or training as may be 
                required to qualify them for enrollment;
          (2) publicizing existing sources of financial aid 
        available to Indians enrolled in any course of study 
        referred to in paragraph (1) [of this subsection] or 
        who are undertaking training necessary to qualify them 
        to enroll in any such course of study; or
          (3) establishing other programs which the Secretary 
        determines will enhance and facilitate the enrollment 
        of Indians in, and the subsequent pursuit and 
        completion by them of, courses of study referred to in 
        paragraph (1) [of this subsection].
    (b) [Application for grant; submittal and approval; 
preference; payment] Funding._
          (1) Application.--Funds under this section shall 
        require that [No grant may be made under this section 
        unless] an application [therefor] has been submitted 
        to, and approved by, the Secretary. Such application 
        shall be in such form, submitted in such manner, and 
        contain such information, as the Secretary shall by 
        regulation prescribe pursuant to this Act. The 
        Secretary shall give a preference to applications 
        submitted by Tribal Health Programs or Urban Indian 
        Organizations [Indian tribes or tribal organizations].
          (2) Amount of funds; payment.--The amount of funds 
        provided to entities [any grant] under this section 
        shall be determined by the Secretary. Payments pursuant 
        to [grants under] this section may be made in advance 
        or by way of reimbursement, and at such intervals and 
        on such conditions as [the Secretary finds necessary.] 
        provided for in regulations issued pursuant to this 
        Act. To the extent not otherwise prohibited by law, 
        funding commitments shall be for 3 years, as provided 
        in regulations issued pursuant to this Act.
    (c) Definition of Indian.--For purposes of this section and 
sections 103 and 104, the term `Indian' shall, in addition to 
the meaning given that term in section 4, also mean any 
individual who is an Urban Indian.

Sec. 1613. Health P[p]rofessions P[p]reparatory S[s]cholarship 
                    P[p]rogram for Indians

    (a) [Requirements] Scholarships Authorized._
    The Secretary, acting through the Service, shall provide 
scholarships [make scholarship grants] to Indians who--
          (1) have successfully completed their high school 
        education or high school equivalency; and
          (2) have demonstrated the potential [capability] to 
        successfully complete courses of study in the health 
        professions.
    (b) Purposes.--[and duration of grants; preprofessional and 
pregraduate education]
    Scholarships provided [grants made] pursuant to this 
section shall be for the following purposes:
          (1) Compensatory preprofessional education of any 
        recipient [grantee], such scholarship not to exceed 
        [two] 2 years on a full-time basis (or the part-time 
        equivalent thereof, as determined by the Secretary 
        pursuant to regulations issued under this Act).
          (2) Pregraduate education of any recipient [grantee] 
        leading to a baccalaureate degree in an approved course 
        of study preparatory to a field of study in a health 
        profession, suchscholarship not to exceed 4 years [(or 
the part-time equivalent thereof, as determined by the Secretary)]. An 
extension of up to 2 years (or the part-time equivalent thereof, as 
determined by the Secretary pursuant to regulations issued pursuant to 
this Act) may be approved.
    (c) [Covered expenses] Other Conditions._
    Scholarships [grants made] under this section--
          (1) may cover costs of tuition, books, 
        transportation, board, and other necessary related 
        expenses of a recipient [grantee] while attending 
        school[.];
          (2) shall not be denied solely on the basis of the 
        applicant's scholastic achievement if such applicant 
        has been admitted to, or maintained good standing at, 
        an accredited institution; and
          (3) shall not be denied solely by reason of such 
        applicant's eligibility for assistance or benefits 
        under any other Federal program.
    [(d) Basis for denial of assistance
    [The Secretary shall not deny scholarship assistance to an 
eligible applicant under this section solely on the basis of 
the applicant's scholastic achievement if such applicant has 
been admitted to, or maintained good standing at, an accredited 
institution.
    [(e) Eligibility for assistance under other Federal 
programs
    [The Secretary shall not deny scholarship assistance to an 
eligible applicant under this section solely by reason of such 
applicant's eligibility for assistance or benefits under any 
other Federal program.]

Sec. 1613a. Indian H[h]ealth P[p]rofessions S[s]cholarships

    (a) In General.--[authority]
          (1) Authority.--[In order to provide health 
        professionals to Indians, Indian tribes, tribal 
        organizations, and urban Indian organizations, t]The 
        Secretary, acting through the Service [and in 
        accordance with this section], shall make scholarships 
        [grants] to Indians who are enrolled full or part time 
        in [appropriately] accredited schools [and] pursuing 
        courses of study in the health professions. Such 
        scholarships shall be designated Indian Health 
        Scholarships and shall be made in accordance with 
        section 338A of the Public Health Services Act (42 
        U.S.C. 254l) [of Title 42], except as provided in 
        subsection (b) of this section.
          (2) Allocation by formula.--Except as provided in 
        paragraph (3), the funding authorized by this section 
        shall be allocated by Service Area by a formula 
        developed in consultation with Indian Tribes, Tribal 
        Organizations, and Urban Indian Organizations. Such 
        formula shall consider the human resource development 
        needs in each Service Area.
          (3) Continuity of prior scholarships.--Paragraph (2) 
        shall not apply with respect to individual recipients 
        of scholarships provided under this section (as in 
        effect 1 day prior to the date of the enactment of the 
        Indian Health Care Improvement Act Amendments of 2004) 
        until such time as the individual completes the course 
        of study that is supported through such scholarship.
          (4) Certain delegation not allowed.--The 
        administration of this section shall be a 
        responsibility of the Assistant Secretary and shall not 
        be delegated in a Funding Agreement.
    (b) [Recipients; a] Active D[d]uty S[s]ervice 
O[o]bligation.--
          [(1) The Secretary, acting through the Service, shall 
        determine who shall receive scholarships under 
        subsection (a) of this section and shall determine the 
        distribution of such scholarships among such health 
        professions on the basis of the relative needs of 
        Indians for additional service in such health 
        professions.
          [(2) An individual shall be eligible for a 
        scholarship under subsection (a) of this section in any 
        year in which such individual is enrolled full or part 
        time in a course of study referred to in subsection (a) 
        of this section.]
          (1)[(3)(A)] Obligation met.--The [A]active duty 
        service obligation under a written contract with the 
        Secretary under section 338A of the Public Health 
        Service Act (42 U.S.C. 254l) [of Title 42] that an 
        [individual] Indian has entered into under that section 
        shall, if that individual is a recipient of an Indian 
        Health Scholarship, be met in full-time practice on an 
        equivalent year-for-year obligation, by service in one 
        or more of the following:[--]
                  (A)[(i) i]In an [the] Indian Health Program. 
                [Service;]
                          [(ii) in a program conducted under a 
                        contractentered into under the Indian 
Self-Determination Act [25 U.S.C.A. Sec. 450f et seq.];]
                  (B)[(iii) i]In a program assisted under title 
                V [subchapter IV] of this Act. [chapter;]
                  (C)[(iv) i]In the private practice of the 
                applicable profession if, as determined by the 
                Secretary, in accordance with guidelines 
                promulgated by the Secretary, such practice is 
                situated in a physician or other health 
                professional shortage area and addresses the 
                health care needs of a substantial number of 
                Indians. [; or]
          (2)[(B)] Obligation deferred.--At the request of any 
        individual who has entered into a contract referred to 
        in paragraph (1) [subparagraph (A)] and who receives a 
        degree in medicine (including osteopathic or allopathic 
        medicine), dentistry, optometry, podiatry, or pharmacy, 
        the Secretary shall defer the active duty service 
        obligation of that individual under that contract, in 
        order that such individual may complete any internship, 
        residency, or other advanced clinical training that is 
        required for the practice of that health profession, 
        for an appropriate period (in years, as determined by 
        the Secretary), subject to the following conditions:
                  (A)[(i)] No period of internship, residency, 
                or other advanced clinical training shall be 
                counted as satisfying any period of obligated 
                service [that is required] under this 
                subsection.
                  (B)[(ii)] The active duty service obligation 
                of that individual shall commence not later 
                than 90 days after the completion of that 
                advanced clinical training (or by a date 
                specified by the Secretary).
                  (C)[(iii)] The active duty service obligation 
                will be served in the health profession of that 
                individual[,] in a manner consistent with 
                paragraph (1) [clauses (i) through (v) of 
                subparagraph (A)].
                  (D)[(C)] A recipient of a[n Indian Health 
                S]scholarship under this section may, at the 
                election of the recipient, meet the active duty 
                service obligation described in paragraph (1) 
                [subparagraph (A)] by service in a program 
                specified under [in] that paragraph 
                [subparagraph] that--
                          (i) is located on the reservation of 
                        the Indian T[t]ribe in which the 
                        recipient is enrolled; or
                          (ii) serves the Indian T[t]ribe in 
                        which the recipient is enrolled.
          (3)[(D)] Priority when making assignments.--Subject 
        to paragraph (2) [subparagraph (C)], the Secretary, in 
        making assignments of Indian Health Scholarship 
        recipients required to meet the active duty service 
        obligation described in paragraph (1) [subparagraph 
        (A)], shall give priority to assigning individuals to 
        service in those programs specified in paragraph (1) 
        [subparagraph (A)] that have a need for health 
        professionals to provide health care services as a 
        result of individuals having breached contracts entered 
        into under this section.
    (c)[(4)] Part-Time Students.--In the case of an individual 
receiving a scholarship under this section who is enrolled part 
time in an approved course of study--
          (1)[(A) such scholarship shall be for a period of 
        years not to exceed the] part-time equivalent of 4 
        years, as determined by the Area Office [Secretary];
          (2)[(B)] the period of obligated service described in 
        subsection (b)(1) [paragraph (3)(A)] shall be equal to 
        the greater of--
                  (A)[(i)] the part-time equivalent of 1 [one] 
                year for each year for which the individual was 
                provided a scholarship (as determined by the 
                Area Office [Secretary]); or
                  (B)[(ii) two] 2 years; and
          (3)[(C)] the amount of the monthly stipend specified 
        in section 338A(g)(1)(B) of the Public Health Service 
        Act (42 U.S.C. 254l(g)(1)(B)) [of Title 42] shall be 
        reduced pro rata (as determined by the Secretary) based 
        on the number of hours such student is enrolled.
    (d) Breach of Contract.--
          (1) Specified breaches.--An individual shall be 
        liable to the United States for the amount which has 
        been paid to the individual, or on behalf of the 
        individual, under a contract entered into with the 
        Secretary under this section on or after the date of 
        the enactment of the Indian Health Care Improvement Act 
        Amendments of 2004 if that individual--
          [(5)(A) An individual who has, on or after October 
        29, 1992, entered into a written contract with the 
        Secretary under this section and who--]
                  (A)[(i)] fails to maintain an acceptable 
                level of academic standing in the educational 
                institution in which he or she is enrolled 
                (such level determined by the educational 
                institution under regulations of the 
                Secretary)[,];
                  (B)[(ii)] is dismissed from such educational 
                institution for disciplinary reasons[,];
                  (C)[(iii)] voluntarily terminates the 
                training in such an educational institution for 
                which he or she is provided a scholarship under 
                such contract before the completion of such 
                training[,]; or
                  (D)[(iv)] fails to accept payment, or 
                instructs the educational institution in which 
                he or she is enrolled not to accept payment, in 
                whole or in part, of a scholarship under such 
                contract, in lieu of any service obligation 
                arising under such contract[, shall be liable 
                to the United States for the amount which has 
                been paid to him, on his behalf, under the 
                contract].
          (2)[(B)] Other breaches.--If for any reason not 
        specified in paragraph (1) [subparagraph (A)] an 
        individual breaches a [his] written contract by failing 
        either to begin such individual's service obligation 
        required under such contract [this section] or to 
        complete such service obligation, the United States 
        shall be entitled to recover from the individual an 
        amount determined in accordance with the formula 
        specified in subsection (l) of section 110 [1616a of 
        this title] in the manner provided for in such 
        subsection.
          (3)[(C)] Cancellation upon death of recipient.--Upon 
        the death of an individual who receives an Indian 
        Health Scholarship, any obligation of that individual 
        for service or payment that relates to that scholarship 
        shall be canceled.
          (4)[(D)] Waivers and suspensions.--The Secretary 
        shall provide for the partial or total waiver or 
        suspension of any obligation of service or payment of a 
        recipient of an Indian Health Scholarship if the 
        Secretary, in consultation with the Area Office, Indian 
        Tribes, Tribal Organizations, and Urban Indian 
        Organizations, determines that--
                  (A)[(i)] it is not possible for the recipient 
                to meet that obligation or make that payment;
                  (B)[(ii)] requiring that recipient to meet 
                that obligation or make that payment would 
                result in extreme hardship to the recipient; or
                  (C)[(iii)] the enforcement of the requirement 
                to meet the obligation or make the payment 
                would be unconscionable.
          (5)[(E)] Extreme hardship.--Notwithstanding any other 
        provision of law, in any case of extreme hardship or 
        for other good cause shown, the Secretary may waive, in 
        whole or in part, the right of the United States to 
        recover funds made available under this section.
          (6)[(F)] Bankruptcy.--Notwithstanding any other 
        provision of law, with respect to a recipient of an 
        Indian Health Scholarship, no obligation for payment 
        may be released by a discharge in bankruptcy under 
        [T]title 11, United States Code, unless that discharge 
        is granted after the expiration of the 5-year period 
        beginning on the initial date on which that payment is 
        due, and only if the bankruptcy court finds that the 
        nondischarge of the obligation would be unconscionable.
    [(c) Placement Office
    [The Secretary shall, acting through the Service, establish 
a Placement Office to develop and implement a national policy 
for the placement, to available vacancies within the Service, 
of Indian Health Scholarship recipients required to meet the 
active duty service obligation prescribed under section 254m of 
Title 42 without regard to any competitive personnel system, 
agency personnel limitation, or Indian preference policy.]

Sec. 105. American Indians into Psychology Program

    (a) Grants Authorized.--The Secretary, acting through the 
Service, shall provide funding grants to at least 3 colleges 
and universities for the purpose of developing and maintaining 
Indian psychology career recruitment programs as a means of 
encouraging Indians to enter the mental health field. These 
programs shall be located at various locations throughout the 
country to maximize their availability to Indian students and 
new programs shall be established in different locations from 
time to time.
    (b) Quentin N. Burdick Program Grant.--The Secretary shall 
provide a grant authorized under subsection (a) to develop and 
maintain a program at the University of North Dakota to be 
known as the `Quentin N. Burdick American Indians Into 
Psychology Program'. Such program shall, to the maximum extent 
feasible, coordinate with the Quentin N. Burdick Indian Health 
Programs authorized under section 117(b), the Quentin N. 
Burdick American Indians Into Nursing Program authorized under 
section 115(e), and existing university research and 
communications networks.
    (c) Regulations.--The Secretary shall issue regulations 
pursuantto this Act for the competitive awarding of funds 
provided under this section.
    (d) Conditions of Grant.--Applicants under this section 
shall agree to provide a program which, at a minimum--
          (1) provides outreach and recruitment for the health 
        professions to Indian communities including elementary, 
        secondary, and accredited and accessible community 
        colleges that will be served by the program;
          (2) incorporates a program advisory board comprised 
        of representatives from the tribes and communities that 
        will be served by the program;
          (3) provides summer enrichment programs to expose 
        Indian students to the various fields of psychology 
        through research, clinical, and experimental 
        activities;
          (4) provides stipends to undergraduate and graduate 
        students to pursue a career in psychology;
          (5) develops affiliation agreements with tribal 
        colleges and universities, the Service, university 
        affiliated programs, and other appropriate accredited 
        and accessible entities to enhance the education of 
        Indian students;
          (6) to the maximum extent feasible, uses existing 
        university tutoring, counseling, and student support 
        services; and
          (7) to the maximum extent feasible, employs qualified 
        Indians in the program.
    (e) Active Duty Service Requirement.--The active duty 
service obligation prescribed under section 338C of the Public 
Health Service Act (42 U.S.C. 254m) shall be met by each 
graduate who receives a stipend described in subsection (d)(4) 
that is funded under this section. Such obligation shall be met 
by service--
          (1) in an Indian Health Program;
          (2) in a program assisted under title V of this Act; 
        or
          (3) in the private practice of psychology if, as 
        determined by the Secretary, in accordance with 
        guidelines promulgated by the Secretary, such practice 
        is situated in a physician or other health professional 
        shortage area and addresses the health care needs of a 
        substantial number of Indians.

Sec. 106. Funding for Tribes for Scholarship Programs

    (a) In General.--
          (1) Funding authorized.--The Secretary, acting 
        through the Service, shall make funds available to 
        Tribal Health Programs for the purpose of providing 
        scholarships for Indians to serve as health 
        professionals in Indian communities.
          (2) Amount.--Amounts available under paragraph (1) 
        for any fiscal year shall not exceed 5 percent of the 
        amounts available for each fiscal year for Indian 
        Health Scholarships under section 104.
          (3) Application.--An application for funds under 
        paragraph (1) shall be in such form and contain such 
        agreements, assurances, and information as consistent 
        with this section.
    (b) Requirements.--
          (1) In general.--A Tribal Health Program receiving 
        funds under subsection (a) shall provide scholarships 
        to Indians in accordance with the requirements of this 
        section.
          (2) Costs.--With respect to costs of providing any 
        scholarship pursuant to subsection (a)--
                  (A) 80 percent of the costs of the 
                scholarship shall be paid from the funds made 
                available pursuant to subsection (a)(1) 
                provided to the Tribal Health Program; and
                  (B) 20 percent of such costs may be paid from 
                any other source of funds.
    (c) Course of Study.--A Tribal Health Program shall provide 
scholarships under this section only to Indians enrolled or 
accepted for enrollment in a course of study (approved by the 
Secretary) in one of the health professions contemplated by 
this Act.
    (d) Contract.--In providing scholarships under subsection 
(b), the Secretary and the Tribal Health Program shall enter 
into a written contract with each recipient of such 
scholarship. Such contract shall--
          (1) obligate such recipient to provide service in an 
        Indian Health Program or Urban Indian Organization, in 
        the same Service Area where the Tribal Health Program 
        providing the scholarship is located, for--
                  (A) a number of years for which the 
                scholarship is provided (or the part-time 
                equivalent thereof, as determined by the 
                Secretary), or for a period of 2 years, 
                whichever period is greater; or
                  (B) such greater period of time as the 
                recipient and the Tribal Health Program may 
                agree;
          (2) provide that the amount of the scholarship--
                  (A) may only be expended for--
                          (i) tuition expenses, other 
                        reasonable educational expenses, and 
                        reasonable living expenses incurred in 
                        attendance at the educational 
                        institution; and
                          (ii) payment to the recipient of a 
                        monthly stipend of not more than the 
                        amount authorized by section 
                        338(g)(1)(B) of the Public Health 
                        Service Act (42 U.S.C. 254m(g)(1)(B)), 
                        such amount to be reduced pro rata (as 
                        determined by the Secretary) based on 
                        the number of hours such student is 
                        enrolled; and may not exceed, for any 
                        year of attendance for which the 
                        scholarship is provided, the total 
                        amount required for the year for the 
                        purposes authorized in this clause; and
                  (B) may not exceed, for any year of 
                attendance for which the scholarship is 
                provided, the total amount required for the 
                year for the purposes authorized in 
                subparagraph (A);
          (3) require the recipient of such scholarship to 
        maintain an acceptable level of academic standing as 
        determined by the educational institution in accordance 
        with regulations issued pursuant to this Act; and
          (4) require the recipient of such scholarship to meet 
        the educational and licensure requirements appropriate 
        to each health profession.
    (e) Breach of Contract.--
          (1) Specific breaches.--An individual who has entered 
        into a written contract with the Secretary and a Tribal 
        Health Program under subsection (d) shall be liable to 
        the United States for the Federal share of the amount 
        which has been paid to him or her, or on his or her 
        behalf, under the contract if that individual--
                  (A) fails to maintain an acceptable level of 
                academic standing in the educational 
                institution in which he or she is enrolled 
                (such level as determined by the educational 
                institution under regulations of the 
                Secretary);
                  (B) is dismissed from such educational 
                institution for disciplinary reasons;
                  (C) voluntarily terminates the training in 
                such an educational institution for which he or 
                she is provided a scholarship under such 
                contract before the completion of such 
                training; or
                  (D) fails to accept payment, or instructs the 
                educational institution in which he or she is 
                enrolled not to accept payment, in whole or in 
                part, of a scholarship under such contract, in 
                lieu of any service obligation arising under 
                such contract.
          (2) Other breaches.--If for any reason not specified 
        in paragraph (1), an individual breaches a written 
        contract by failing to either begin such individual's 
        service obligation required under such contract or to 
        complete such service obligation, the United States 
        shall be entitled to recover from the individual an 
        amount determined in accordance with the formula 
        specified in subsection (l) of section 110 in the 
        manner provided for in such subsection.
          (3) Cancellation upon death of recipient.--Upon the 
        death of an individual who receives an Indian Health 
        Scholarship, any outstanding obligation of that 
        individual for service or payment that relates to that 
        scholarship shall be canceled.
          (4) Information.--The Secretary may carry out this 
        subsection on the basis of information received from 
        Tribal Health Programs involved or on the basis of 
        information collected through such other means as the 
        Secretary deems appropriate.
    (f) Relation to Social Security Act.--The recipient of a 
scholarship under this section shall agree, in providing health 
care pursuant to the requirements herein--
          (1) not to discriminate against an individual seeking 
        care on the basis of the ability of the individual to 
        pay for such care or on the basis that payment for such 
        care will be made pursuant to a program established in 
        title XVIII of the Social Security Act or pursuant to 
        the programs established in title XIX or title XXI of 
        such Act; and
          (2) to accept assignment under section 
        1842(b)(3)(B)(ii) of the Social Security Act for all 
        services for which payment may be made under part B of 
        title XVIII of such Act, and to enter intoan 
appropriate agreement with the State agency that administers the State 
plan for medical assistance under title XIX, or the State child health 
plan under title XXI, of such Act to provide service to individuals 
entitled to medical assistance or child health assistance, 
respectively, under the plan.
    (g) Continuance of Funding.--The Secretary shall make 
payments under this section to a Tribal Health Program for any 
fiscal year subsequent to the first fiscal year of such 
payments unless the Secretary determines that, for the 
immediately preceding fiscal year, the Tribal Health Program 
has not complied with the requirements of this section.

Sec. 1614. Indian H[h]ealth S[s]ervice E[e]xtern P[p]rograms

    (a) Employment Preference.--[of scholarship grantees during 
nonacademic periods] Any individual who receives a scholarship 
pursuant to section 104 or 106 shall be given preference for 
employment in the Service, or may be employed by a Tribal 
Health Program or an Urban Indian Organization, or other 
agencies of the Department as available, during any nonacademic 
period of the year.
    (b) Not Counted Toward Active Duty Service Obligation.--
    [Any individual who receives a scholarship grant pursuant 
to section 1613a of this title shall be entitled to employment 
in the Service during any nonacademic period of the year.] 
Periods of employment pursuant to this subsection shall not be 
counted in determining [the] fulfillment of the service 
obligation incurred as a condition of the scholarship [grant].
    (c) Timing; Length of Employment.--
    [(b) Employment of medical and other students during 
nonacademic periods]
    Any individual enrolled in a program, including a high 
school program, authorized under section 102(a) [course of 
study in the health professions] may be employed by the Service 
or by a Tribal Health Program or an Urban Indian Organization 
during any nonacademic period of the year. Any such employment 
shall not exceed 120 [one hundred and twenty] days during any 
calendar year.
    (d) Nonapplicability of Competitive Personnel System.--
    [(c) Employment without regard to competitive personnel 
system or agency personnel limitation; compensation]
    Any employment pursuant to this section shall be made 
without regard to any competitive personnel system or agency 
personnel limitation and to a position which will enable the 
individual so employed to receive practical experience in the 
health profession in which he or she is engaged in study. Any 
individual so employed shall receive payment for his or her 
services comparable to the salary he or she would receive if he 
or she were employed in the competitive system. Any individual 
so employed shall not be counted against any employment ceiling 
affecting the Service or the Department [of Health and Human 
Services].

Sec. 1615. Continuing E[e]ducation A[a]llowances

    [(a) Discretionary authority; scope of activities]
    In order to encourage health professionals, including 
community health representatives and emergency medical 
technicians, [physicians, dentists, nurses, and other health 
professionals] to join or continue in an Indian Health Program 
or an Urban Indian Organization [the Service] and to provide 
their services in the rural and remote areas where a 
significant portion of [the] Indians [people] reside[s], the 
Secretary, acting through the Service, may provide allowances 
to health professionals employed in an Indian Health Program or 
an Urban Indian Organization [the Service] to enable them for a 
period of time each year prescribed by regulation of the 
Secretary to take leave of their duty stations for professional 
consultation and refresher training courses.
    [(b) Limitation
    [Of amounts appropriated under the authority of this 
subchapter for each fiscal year to be used to carry out this 
section, not more than $1,000,000 may be used to establish 
postdoctoral training programs for health professionals.]

Sec. 1616. Community Health Representative Program

    (a) In General.--Under the authority of the Act of November 
2, 1921 (25 U.S.C. 13) (commonly [, popularly] known as the 
Snyder Act), the Secretary, acting through the Service, shall 
maintain a Community Health Representative Program under which 
Indian Health Programs [the Service]--
          (1) provide[s] for the training of Indians as 
        community health representatives; [health 
        paraprofessionals,] and
          (2) use[s] such community health 
representatives[paraprofessionals] in the provision of health care, 
health promotion, and disease prevention services to Indian 
communities.
    (b) Duties._The [Secretary, acting through the] Community 
Health Representative Program of the Service, shall--
          (1) provide a high standard of training for 
        [paraprofessionals to C]community [H]health 
        [R]representatives to ensure that the [C]community 
        [H]health [R]representatives provide quality health 
        care, health promotion, and disease prevention services 
        to the Indian communities served by [such] the 
        Program[,];
          (2) in order to provide such training, develop and 
        maintain a curriculum that--
                  (A) combines education in the theory of 
                health care with supervised practical 
                experience in the provision of health care[,]; 
                and
                  (B) provides instruction and practical 
                experience in health promotion and disease 
                prevention activities, with appropriate 
                consideration given to lifestyle factors that 
                have an impact on Indian health status, such as 
                alcoholism, family dysfunction, and poverty[,];
          (3) maintain a system which identifies the needs of 
        [C]community [H]health [R]representatives for 
        continuing education in health care, health promotion, 
        and disease prevention, and develop [maintain] programs 
        that meet the needs for [such] continuing education[,];
          (4) maintain a system that provides close supervision 
        of Community Health Representatives[,];
          (5) maintain a system under which the work of 
        Community Health Representatives is reviewed and 
        evaluated[,]; and
          (6) promote [t]Traditional [h]Health [c]Care 
        [p]Practices of the Indian [t]Tribes served consistent 
        with the Service standards for the provision of health 
        care, health promotion, and disease prevention.

Sec. 1616a. Indian Health Service Loan Repayment Program

    (a) Establishment
          [(1)] The Secretary, acting through the Service, 
        shall establish and administer a program to be known as 
        the [Indian Health] Service Loan Repayment Program 
        (hereinafter referred to as the ``Loan Repayment 
        Program'') in order to ensure [assure] an adequate 
        supply of trained health professionals necessary to 
        maintain accreditation of, and provide health care 
        services to Indians through, Indian [h]Health 
        [p]Programs and Urban Indian Organizations.
          [(2) For the purposes of this section--
                  [(A) the term ``Indian health program'' means 
                any health program or facility funded, in whole 
                or part, by the Service for the benefit of 
                Indians and administered--
                          [(i) directly by the Service;
                          [(ii) by any Indian tribe or tribal 
                        or Indian organization pursuant to a 
                        contract under--
                                  [(I) the Indian Self-
                                Determination Act [25 U.S.C.A. 
                                Sec. 450f et seq.], or
                                  [(II) section 23 of the Act 
                                of April 30, 1908 (25 U.S.C. 
                                47), popularly known as the 
                                ``Buy-Indian'' Act; or
                          [(iii) by an urban Indian 
                        organization pursuant to subchapter IV 
                        of this chapter; and
                  [(B) the term ``State'' has the same meaning 
                given such term in section 254d(i)(4) of Title 
                42.]
    (b) Eligible Individuals.--[Eligibility]
    To be eligible to participate in the Loan Repayment 
Program, an individual must--
          (1)(A) be enrolled--
                  (i) in a course of study or program in an 
                accredited institution[,] (as determined by the 
                Secretary under section 338B(b)(1)(c)(i) of the 
                Public Health Service Act (42 U.S.C. 254l-
                1(b)(1)(c)(i)))[, within any State] and be 
                scheduled to complete such course of study in 
                the same year such individual applies to 
                participate in such program; or
                  (ii) in an approved graduate training program 
                in a health profession; or
          (B) have--
                  (i) a degree in a health profession; and
                  (ii) a license to practice a health 
                profession [in a State];
          (2)(A) be eligible for, or hold, an appointment as a 
        commissioned officer in the Regular or Reserve Corps of 
        the Public Health Service;
          (B) be eligible for selection for civilian service in 
        the Regular or Reserve Corps of the Public Health 
        Service;
          (C) meet the professional standards for civil service 
        employment in the [Indian Health] Service; or
          (D) be employed in an Indian [h]Health [p]Program or 
        Urban Indian Organization without a service obligation; 
        and
          (3) submit to the Secretary an application for a 
        contract described in subsection (e) [(f) of this 
        section].
    (c) Application [and Contract Forms].--
          (1) Information to be included with forms.--In 
        disseminating application forms and contract forms to 
        individuals desiring to participate in the Loan 
        Repayment Program, the Secretary shall include with 
        such forms a fair summary of the rights and liabilities 
        of an individual whose application is approved (and 
        whose contract is accepted) by the Secretary, including 
        in the summary a clear explanation of the damages to 
        which the United States is entitled under subsection 
        (1) [of this section] in the case of the individual's 
        breach of the contract. The Secretary shall provide 
        such individuals with sufficient information regarding 
        the advantages and disadvantages of service as a 
        commissioned officer in the Regular or Reserve Corps of 
        the Public Health Service or a civilian employee of the 
        [Indian Health] Service to enable the individual to 
        make a decision on an informed basis.
          (2) Clear language.--The application form, contract 
        form, and all other information furnished by the 
        Secretary under this section shall be written in a 
        manner calculated to be understood by the average 
        individual applying to participate in the Loan 
        Repayment Program.
          (3) Timely availability of forms.--The Secretary 
        shall make such application forms, contract forms, and 
        other information available to individuals desiring to 
        participate in the Loan Repayment Program on a date 
        sufficiently early to ensure that such individuals have 
        adequate time to carefully review and evaluate such 
        forms and information.
    (d) Priorities.--[Vacancies; priority]
          (1) List.--Consistent with subsection (k) [paragraph 
        (3)], the Secretary[, acting through the Service and in 
        accordance with subsection (k), of this section,] shall 
        annually--
                  (A) identify the positions in each Indian 
                [h]Health [p]Program or Urban Indian 
                Organization for which there is a need or a 
                vacancy[,]; and
                  (B) rank those positions in order of 
                priority.
          (2) Approvals.--Notwithstanding [Consistent with] the 
        priority determined under paragraph (1), the Secretary, 
        in determining which applications under the Loan 
        Repayment Program to approve (and which contracts to 
        accept), shall--
                  (A) give first priority to applications made 
                by individual Indians; and
                  (B) after making determinations on all 
                applications submitted by individual Indians as 
                required under subparagraph (A), give priority 
                to--
                          (i) individuals recruited through the 
                        efforts of an Indian Health Program or 
                        Urban Indian Organization; and [tribes 
                        or tribal or Indian organizations.]
                          (ii) other individuals based on the 
                        priority rankings under paragraph (1).
          [(3)(A) Subject to subparagraph (B), of the total 
        amounts appropriated for each of the fiscal years 1993, 
        1994, and 1995 for loan repayment contracts under this 
        section, the Secretary shall provide that--
                  [(i) not less than 25 percent be provided to 
                applicants who are nurses, nurse practitioners, 
                or nurse midwives; and
                  [(ii) not less than 10 percent be provided to 
                applicants who are mental health professionals 
                (other than applicants described in clause 
                (i)).
          [(B) The requirements specified in clause (i) or 
        clause (ii) of subparagraph (A) shall not apply if the 
        Secretary does not receive the number of applications 
        from the individuals described in clause (i) or clause 
        (ii), respectively, necessary to meet such 
        requirements.]
    (e) Recipient Contracts.--[Approval]
          (1) Contract required.--An individual becomes a 
        participant in the Loan Repayment Program only upon the 
        Secretary and the individual entering into a written 
        contract described in paragraph (2) [subsection (f) of 
        this section].
          (2) Contents of contract.--[The Secretary shall 
        provide written notice to an individual promptly on--
                  [(A) the Secretary's approving, under 
                paragraph (1), of the individual's 
                participation in the Loan Repayment Program, 
                including extensions resulting in an aggregate 
                period of obligated service in excess of 4 
                years; or
                  [(B) the Secretary's disapproving an 
                individual's participation in such Program.
    [(f) Contract terms]
          The written contract referred to in this section 
        between the Secretary and an individual shall contain--
                  (A)[(1)] an agreement under which--
                          (i)[(A)] subject to subparagraph 
                        (C)[(3)], the Secretary agrees--
                                  (I)[(i)] to pay loans on 
                                behalf of the individual in 
                                accordance with the provisions 
                                of this section[,]; and
                                  (II)[(ii)] to accept (subject 
                                to the availability of 
                                appropriated funds for carrying 
                                out this section) the 
                                individual into the Service or 
                                place the individual with a 
                                Tribal Health Program or Urban 
                                Indian Organization [tribe or 
                                Indian organization] as 
                                provided in clause (ii)(III); 
                                [subparagraph (B)(iii),] and
                          (ii)[(B)] subject to subparagraph 
                        (C)[(3)], the individual agrees--
                                  (I)[(i)] to accept loan 
                                payments on behalf of the 
                                individual;
                                  (II)[(ii)] in the case of an 
                                individual described in 
                                subsection (b)(1)--
                                          (aa)[(I)] to maintain 
                                        enrollment in a course 
                                        of study or training 
                                        described in subsection 
                                        (b)(1)(A) [of this 
                                        section] until the 
                                        individual completes 
                                        the course of study or 
                                        training[,]; and
                                          (bb)[(II)] while 
                                        enrolled in such course 
                                        of study or training, 
                                        to maintain an 
                                        acceptable level of 
                                        academic standing (as 
                                        determined under 
                                        regulations of the 
                                        Secretary by the 
                                        educational institution 
                                        offering such course of 
                                        study or training); and
                                  (III)[(iii)] to serve for a 
                                time period (hereinafter in 
                                this section referred to as the 
                                [``]`period of obligated 
                                service'['']) equal to 2 years 
                                or such longer period as the 
                                individual may agree to serve 
                                in the full-time clinical 
                                practice of such individual's 
                                profession in an Indian 
                                [h]Health [p]Program or Urban 
                                Indian Organization to which 
                                the individual may be assigned 
                                by the Secretary;
                  (B)[(2)] a provision permitting the Secretary 
                to extend for such longer additional periods, 
                as the individual may agree to, the period of 
                obligated service agreed to by the individual 
                under subparagraph (A)(ii)(III) [paragraph 
                (1)(B)(iii)];
                  (C)[(3)] a provision that any financial 
                obligation of the United States arising out of 
                a contract entered into under this section and 
                any obligation of the individual which is 
                conditioned thereon is contingent upon funds 
                being appropriated for loan repayments under 
                this section;
                  (D)[(4)] a statement of the damages to which 
                the United States is entitled under subsection 
                (1) [of this section] for the individual's 
                breach of the contract; and
                  (E)[(5)] such other statements of the rights 
                and liabilities of the Secretary and of the 
                individual, not inconsistent with this section.
    (f) Deadline for Decision on Application.--The Secretary 
shall provide written notice to an individual within 21 days 
on--
          (1) the Secretary's approving, under subsection 
        (e)(1), of the individual's participation in the Loan 
        Repayment Program, including extensions resulting in an 
        aggregate period of obligated service in excess of 4 
        years; or
          (2) the Secretary's disapproving an individual's 
        participation in such Program.
    (g) Payments.--[Loan repayment purposes; maximum amount; 
tax liability reimbursement; schedule of payments]
          (1) In general.--A loan repayment provided for an 
        individual under a written contract under the Loan 
        Repayment Program shall consist of payment, in 
        accordance with paragraph (2), on behalf of the 
        individual of the principal, interest, and related 
        expenses on government and commercial loans received by 
        the individual regarding the undergraduate or graduate 
        education of the individual (or both), which loans were 
        made for--
                  (A) tuition expenses;
                  (B) all other reasonable educational 
                expenses, including fees, books, and laboratory 
                expenses, incurred by the individual; and
                  (C) reasonable living expenses as determined 
                by the Secretary.
          (2)[(A)] Amount.--For each year of obligated service 
        that an individual contracts to serve under subsection 
        (e),[(f) of this section] the Secretary may pay up to 
        $35,000 [(]or an amount equal to the amount specified 
        in section 338B(g)(2)(A) of the Public Health Service 
        Act, whichever is more, [254l-1(g)(2)(A) of Title 42)] 
        on behalf of the individual for loans described in 
        paragraph (1). In making a determination of the amount 
        to pay for a year of such service by an individual, the 
        Secretary shall consider the extent to which each such 
        determination--
                  (A)[(i)] affects the ability of the Secretary 
                to maximize the number of contracts that can be 
                provided under the Loan Repayment Program from 
                the amounts appropriated for such contracts;
                  (B)[(ii)] provides an incentive to serve in 
                Indian [h]Health [p]Programs and Urban Indian 
                Organizations with the greatest shortages of 
                health professionals; and
                  (C)[(iii)] provides an incentive with respect 
                to the health professional involved remaining 
                in an Indian [h]Health [p]Program or Urban 
                Indian Organization with such a health 
                professional shortage, and continuing to 
                provide primary health services, after the 
                completion of the period of obligated service 
                under the Loan Repayment Program.
          (3)[(B)] Timing.--Any arrangement made by the 
        Secretary for the making of loan repayments in 
        accordance with this subsection shall provide that any 
        repayments for a year of obligated service shall be 
        made no later than the end of the fiscal year in which 
        the individual completes such year of service.
          (4)[(3)] For the purpose of providing reimbursements 
        for tax liability resulting from payments under 
        paragraph (2) on behalf of an individual, the 
        Secretary--
                  (A) in addition to such payments, may make 
                payments to the individual in an amount not 
                less than 20 percent and not more than 39 
                percent of the total amount of loan repayments 
                made for the taxable year involved; and
                  (B) may make such additional payments as the 
                Secretary determines to be appropriate with 
                respect to such purpose.
          (5)[(4)] Payment Schedule.--The Secretary may enter 
        into an agreement with the holder of any loan for which 
        payments are made under the Loan Repayment Program to 
        establish a schedule for the making of such payments.
    (h) Employment Ceiling.--[Effect on employment ceiling of 
Department of Health and Human Services]
    Notwithstanding any other provision of law, individuals who 
have entered into written contracts with the Secretary under 
this section[, while undergoing academic training,] shall not 
be counted against any employment ceiling affecting the 
Department [of Health and Human Services] while those 
individuals are undergoing academic training.
    (i) Recruitment.--[Recruiting programs]
    The Secretary shall conduct recruiting programs for the 
Loan Repayment Program and other [health professional programs 
of the] Service manpower programs at educational institutions 
training health professionals or specialists identified in 
subsection (a) [of this section].
    (j) Applicability of Law.--[Prohibition of assignment to 
other government departments]
    Section 214 of the Public Health Service Act (42 U.S.C. 
215) [215 of Title 42] shall not apply to individuals during 
their period of obligated service under the Loan Repayment 
Program.
    (k) Assignment of Individuals.--[Staff needs of health 
programs administered by Indian tribes]
    The Secretary, in assigning individuals to serve in Indian 
[h]Health [p]Programs or Urban Indian Organizations pursuant 
tocontracts entered into under this section, shall--
          (1) ensure that the staffing needs of Tribal [Indian 
        h]Health [p]Programs and Urban Indian Organizations 
        [administered by an Indian tribe or tribal or health 
        organization] receive consideration on an equal basis 
        with programs that are administered directly by the 
        Service; and
          (2) give priority to assigning individuals to Indian 
        [h]Health [p]Programs and Urban Indian Organizations 
        that have a need for health professionals to provide 
        health care services as a result of individuals having 
        breached contracts entered into under this section.
    (l) Breach of Contract.--[Voluntary termination of study or 
dismissal from educational institution; collection of damages]
          (1) Specific breaches.--An individual who has entered 
        into a written contract with the Secretary under this 
        section and has not received a waiver under subsection 
        (m) shall be liable, in lieu of any service obligation 
        arising under such contract, to the United States for 
        the amount which has been paid on such individual's 
        behalf under the contract if that individual [who]--
                  (A) is enrolled in the final year of a course 
                of study and [who]--
                          (i) fails to maintain an acceptable 
                        level of academic standing in the 
                        educational institution in which he or 
                        she is enrolled (such level determined 
                        by the educational institution under 
                        regulations of the Secretary);
                          (ii) voluntarily terminates such 
                        enrollment; or
                          (iii) is dismissed from such 
                        educational institution before 
                        completion of such course of study; or
                  (B) is enrolled in a graduate training 
                program[,] and fails to complete such training 
                program[, and does not receive a waiver from 
                the Secretary under subsection (b)(1)(B)(ii) of 
                this section,].
[shall be liable, in lieu of any service obligation arising 
under such contract, to the United States for the amount which 
has been paid on such individual's behalf under the contract.]
          (2) Other breaches; formula for amount owed.--If, for 
        any reason not specified in paragraph (1), an 
        individual breaches his or her written contract under 
        this section by failing either to begin, or complete, 
        such individual's period of obligated service in 
        accordance with subsection (e)(2) [(f) of this 
        section], the United States shall be entitled to 
        recover from such individual an amount to be determined 
        in accordance with the following formula: A=3Z(t-s/t) 
        in which--
                  (A) [``]`A'[''] is the amount the United 
                States is entitled to recover;
                  (B) [``]`Z'[''] is the sum of the amounts 
                paid under this section to, or on behalf of, 
                the individual and the interest on such amounts 
                which would be payable if, at the time the 
                amounts were paid, they were loans bearing 
                interest based on yields on appropriate 
                marketable Treasury securities [at the maximum 
                legal prevailing rate, as determined by the 
                Treasurer of the United States];
                  (C) [``]`t'[''] is the total number of months 
                in the individual's period of obligated service 
                in accordance with subsection (f) [of this 
                section]; and
                  (D) [``]`s'[''] is the number of months of 
                such period served by such individual in 
                accordance with this section.
          (3) Deductions in medicare payments.--Amounts not 
        paid within such period shall be subject to collection 
        through deductions in [M]medicare payments pursuant to 
        section 1892 of the Social Security Act [1395ccc of 
        Title 42].
          (4) [(3)(A)] Time period for repayment.--Any amount 
        of damages which the United States is entitled to 
        recover under this subsection shall be paid to the 
        United States within the 1-year period beginning on the 
        date of the breach or such longer period beginning on 
        such date as shall be specified by the Secretary.
          (5) Recovery of delinquency.--
                  (A)[(B)] In general.--If damages described in 
                paragraph (4) [subparagraph (A)] are delinquent 
                for 3 months, the Secretary shall, for the 
                purpose of recovering such damages--
                          (i) use [utilize] collection agencies 
                        contracted with by the Administrator of 
                        [the] General Services 
                        [Administration]; or
                          (ii) enter into contracts for the 
                        recovery of such damages with 
                        collection agencies selected by the 
                        Secretary.
                  (B)[(C)] Report.--Each contract for 
                recovering damages pursuant to this subsection 
                shall provide that the contractor will, not 
                less than once each 6 months, submit to the 
                Secretary a status report on the success of the 
                contractor in collecting such damages. Section 
                3718 of [T]title 31, United States Code, shall 
                apply to any such contract to the extent not 
                inconsistent with this subsection.
    (m) Waiver or Suspension of Obligation.--[Cancellation or 
waiver of obligations; bankruptcy discharge]
          [(1) Any obligation of an individual under the Loan 
        Repayment program for service or payment of damages 
        shall be canceled upon the death of the individual.]
          (1) [(2)] In general.--The Secretary shall by 
        regulation provide for the partial or total waiver or 
        suspension of any obligation of service or payment by 
        an individual under the Loan Repayment Program whenever 
        compliance by the individual is impossible or would 
        involve extreme hardship to the individual and if 
        enforcement of such obligation with respect to any 
        individual would be unconscionable.
          (2) Canceled upon death.--Any obligation of an 
        individual under the Loan Repayment Program for service 
        or payment of damages shall be canceled upon the death 
        of the individual.
          (3) Hardship waiver.--The Secretary may waive, in 
        whole or in part, the rights of the United States to 
        recover amounts under this section in any case of 
        extreme hardship or other good cause shown, as 
        determined by the Secretary.
          (4) Bankruptcy.--Any obligation of an individual 
        under the Loan Repayment Program for payment of damages 
        may be released by a discharge in bankruptcy under 
        [T]title 11 of the United States Code only if such 
        discharge is granted after the expiration of the 5-year 
        period beginning on the first date that payment of such 
        damages is required, and only if the bankruptcy court 
        finds that nondischarge of the obligation would be 
        unconscionable.
    (n) [Annual r]Report.--
    The Secretary shall submit to the President, for inclusion 
in each report required to be submitted to [the] Congress under 
section 801 [1671 of this title], a report concerning the 
previous fiscal year which sets forth by Service Area the 
following:[--]
          (1) A list of the health professional positions 
        maintained by Indian Health Programs and Urban Indian 
        Organizations [the Service or by tribal or Indian 
        organizations] for which recruitment or retention is 
        difficult[;].
          (2) [t]The number of Loan Repayment Program 
        applications filed with respect to each type of health 
        profession[;].
          (3) [t]The number of contracts described in 
        subsection (e) [(f) of this section] that are entered 
        into with respect to each health profession[;].
          (4) [t]The amount of loan payments made under this 
        section, in total and by health profession[;].
          (5) [t]The number of scholarships [grants] that are 
        provided under sections 104 and 106 [1613a of this 
        title] with respect to each health profession[;].
          (6) [t]The amount of scholarships [grants] provided 
        under section 104 and 106 [1613a of this title], in 
        total and by health profession[;].
          (7) [t]The number of providers of health care that 
        will be needed by Indian [h]Health [p]Programs and 
        Urban Indian Organizations, by location and profession, 
        during the 3 [three] fiscal years beginning after the 
        date the report is filed[; and].
          (8) [t]The measures the Secretary plans to take to 
        fill the health professional positions maintained by 
        Indian Health Programs or Urban Indian Organizations 
        [the Service or by tribes or tribal or Indian 
        organizations] for which recruitment or retention is 
        difficult.

Sec. 1616a-1. Scholarship and Loan Repayment Recovery Fund

    (a) Establishment
    There is established in the Treasury of the United States a 
fund to be known as the Indian Health Scholarship and Loan 
Repayment Recovery Fund (hereinafter in this section referred 
to as the `LRRF' [``Fund'']). The LRRF [Fund] shall consist of 
such amounts as may be collected from individuals [appropriated 
to the Fund] under section 104(d), section 106(e), and section 
110(l) for breach of contract, such funds as may be 
appropriated to the LRRF, and interest earned on amounts in the 
LRRF [subsection (b) of this section]. All [A]amounts 
collected, appropriated, or earned relative to the LRRF [for 
the Fund] shall remain available until expended.
    [(b) Authorization of appropriations
    [For each fiscal year, there is authorized to be 
appropriated to the Fund an amount equal to the sum of--
          [(1) the amount collected during the preceding fiscal 
        year by the Federal Government pursuant to--
                  [(A) the liability of individuals under 
                subparagraph (A) or (B) of section 1613a(b)(5) 
                of this title for the breach of contracts 
                entered into under section 1613a of this title; 
                and
                  [(B) the liability of individuals under 
                section 1616a(l) of this title for the breach 
                of contracts entered into under section 1616a 
                of this title; and
          [(2) the aggregate amount of interest accruing during 
        the preceding fiscal year on obligations held in the 
        Fund pursuant to subsection (d) of this section and the 
        amount of proceeds from the sale or redemption of such 
        obligations during such fiscal year.]
    (b) [(c)] Use of funds
          (1) By secretary.--Amounts in the LRRF [Fund and 
        available pursuant to appropriation Acts] may be 
        expended by the Secretary, acting through the Service, 
        to make payments to an Indian Health Program--[tribe or 
        tribal organization administering a health care program 
        pursuant to a contract entered into under the Indian 
        Self-Determination Act [25 U.S.C.A. Sec. 450f et 
        seq.]--]
                  (A) to which a scholarship recipient under 
                section 104 and 106 [1613a of this title] or a 
                loan repayment program participant under 
                section 110 [1616a of this title] has been 
                assigned to meet the obligated service 
                requirements pursuant to such sections; and
                  (B) that has a need for a health professional 
                to provide health care services as a result of 
                such recipient or participant having breached 
                the contract entered into under section 104, 
                106, or 110. [1613a of this title or section 
                1616a of this title.]
          (2) By tribal health programs.--A Tribal Health 
        Program, [An Indian tribe or tribal organization] 
        receiving payments pursuant to paragraph (1) may expend 
        the payments to provide scholarships or recruit and 
        employ, directly or by contract, health professionals 
        to provide health care services.
    (c) [(d)] Investment of [excess f]Funds.--
          [(1)] The Secretary of the Treasury shall invest such 
        amounts of the LRRF, except for the appropriated funds, 
        [Fund as such] as the Secretary determines are not 
        required to meet current withdrawals from the LRRF 
        [Fund]. Such investments may be made only in interest[-
        ]bearing obligations of the United States. For such 
        purpose, such obligations may be acquired on original 
        issue at the issue price, or by purchase of outstanding 
        obligations at the market price.
    (d) Sale of Obligations.--[(2)] Any obligation acquired by 
the LRRF [Fund] may be sold by the Secretary of the Treasury at 
the market price.

Sec. 1616b. Recruitment A[a]ctivities

    (a) Reimbursement for Travel.--The Secretary, acting 
through the Service, may reimburse health professionals seeking 
positions with Indian Health Programs or Urban Indian 
Organizations [in the Service], including unpaid student 
volunteers and individuals considering entering into a contract 
under section 110 [1616a of this title], and their spouses, for 
actual and reasonable expenses incurred in traveling to and 
from their places of residence to an area in which they may be 
assigned for the purpose of evaluating such area with respect 
to such assignment.
    (b) Recruitment Personnel.--The Secretary, acting through 
the Service, shall assign one individual in each [a]Area 
[o]Office to be responsible on a full-time basis for 
recruitment activities.

Sec. 1616c. Indian [Tribal r]Recruitment and R[r]etention P[p]rogram

    (a) In General.--[Projects funded on competitive basis]
    The Secretary, acting through the Service, shall fund 
innovative demonstration projects for a period not to exceed 3 
years to enable Tribal Health Programs and Urban Indian 
Organizations to recruit, place, and retain health 
professionals to meet their staffing needs. [, on a competitive 
basis, projects to enable Indian tribes and tribal and Indian 
organizations to recruit, place, and retain health 
professionals to meet the staffing needs of Indian health 
programs (as defined in section 1616a(a)(2) of this title).]
    (b) Eligible Entities; Application.--[Eligibility]
          [(1)] Any Tribal Health Program or Urban Indian 
        Organization [Indian tribe or tribal or Indian 
        organization] may submit an application for funding of 
        a project pursuant to this section.
          [(2) Indian tribes and tribal and Indian 
        organizations under the authority of the Indian Self-
        Determination Act [25 U.S.C.A. Sec. 450f et seq.] shall 
        be given an equal opportunity with programs that are 
        administered directly by the Service to compete for, 
        and receive, grants under subsection (a) of this 
        section for such projects.]

Sec. 1616d. Advanced T[t]raining and R[r]esearch

    (a) Demonstration [Establishment of p]Program
    The Secretary, acting through the Service, shall establish 
a demonstration project [program] to enable health 
professionals who have worked in an Indian Health Program or 
Urban Indian Organization for a substantial period of time to 
pursue advanced training or research in areas of study for 
which the Secretary determines a need exists. [In selecting 
participants for a program established under this subsection, 
the Secretary, acting through the Service, shall give priority 
to applicants who are employed by the Indian Health Service, 
Indian tribes, tribal organization, and urban Indian 
organizations, at the time of the submission of the 
applications.]
    (b) Service Obligation.--[Obligated service]
    An individual who participates in a program under 
subsection (a) [of this section], where the educational costs 
are borne by the Service, shall incur an obligation to serve in 
an Indian [h]Health [p]Program or Urban Indian Organization 
[(as defined in section 1616a(a)(2) of this title)] for a 
period of obligated service equal to at least the period of 
time during which the individual participates in such program. 
In the event that the individual fails to complete such 
obligated service, the individual shall be liable to the United 
States for the period of service remaining. In such event, with 
respect to individuals entering the program after the date of 
the enactment of the Indian Health Care Improvement Act 
Amendments of 2004, [October 29, 1992,] the United States shall 
be entitled to recover from such individual an amount to be 
determined in accordance with the formula specified in 
subsection (l) of section 110 [1616a of this title] in the 
manner provided for in such subsection.
    (c) Equal Opportunity for Participation.--[Eligibility]
    Health professionals from Tribal Health Programs and Urban 
Indian Organizations [Indian tribes and tribal and Indian 
organizations under the authority of the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.]] shall be 
given an equal opportunity to participate in the program under 
subsection (a) [of this section].

[Sec. 1616e. Nursing program

    [(a) Grants
    [The Secretary, acting through the Service, shall provide 
grants to--
          [(1) public or private schools of nursing,
          [(2) tribally controlled community colleges and 
        tribally controlled postsecondary vocational 
        institutions (as defined in section 2397h(2) of Title 
        20), and
          [(3) nurse midwife programs, and nurse practitioner 
        programs, that are provided by any public or private 
        institution,
for the purpose of increasing the number of nurses, nurse 
midwives, and nurse practitioners who deliver health care 
services to Indians.
    [(b) Purposes
    [Grants provided under subsection (a) of this section may 
be used to--
          [(1) recruit individuals for programs which train 
        individuals to be nurses, nurse midwives, or nurse 
        practitioners,
          [(2) provide scholarships to individuals enrolled in 
        such programs that may pay the tuition charged for such 
        program and other expenses incurred in connection with 
        such program, including books, fees, room and board, 
        and stipends for living expenses,
          [(3) provide a program that encourages nurses, nurse 
        midwives, and nurse practitioners to provide, or 
        continue to provide, health care services to Indians,
          [(4) provide a program that increases the skills of, 
        and provides continuing education to, nurses, nurse 
        midwives, and nurse practitioners, or
          [(5) provide any program that is designed to achieve 
        the purpose described in subsection (a) of this 
        section.
    [(c) Application
    [Each application for a grant under subsection (a) of this 
section shall include such information as the Secretary may 
require to establish the connection between the program of the 
applicant and a health care facility that primarily serves 
Indians.
    [(d) Preference
    [In providing grants under subsection (a) of this section, 
the Secretary shall extend a preference to--
          [(1) programs that provide a preference to Indians,
          [(2) programs that train nurse midwives or nurse 
        practitioners,
          [(3) programs that are interdisciplinary, and
          [(4) programs that are conducted in cooperation with 
        a center for gifted and talented Indian students 
        established under section 2624(a) of this title.]

Sec. 115. [(e)] Quentin N. Burdick American Indians Into Nursing 
                    Program

    (a) Grants Authorized.--For the purpose of increasing the 
number of nurses, nurse midwives, and nurse practitioners who 
deliver health care services to Indians, the Secretary, acting 
through the Service, shall provide grants to the following:
          (1) Public or private schools of nursing.
          (2) Tribal colleges or universities.
          (3) Nurse midwife programs and advanced practice 
        nurse programs that are provided by any tribal college 
        or university accredited nursing program, or in the 
        absence of such, any other public or private 
        institutions.
    (b) Use of Grants.--Grants provided under subsection (a) 
may be used for one or more of the following:
          (1) To recruit individuals for programs which train 
        individuals to be nurses, nurse midwives, or advanced 
        practice nurses.
          (2) To provide scholarships to Indians enrolled in 
        such programs that may pay the tuition charged for such 
        program and other expenses incurred in connection with 
        such program, including books, fees, room and board, 
        and stipends for living expenses.
          (3) To provide a program that encourages nurses, 
        nurse midwives, and advanced practice nurses to 
        provide, or continue to provide, health care services 
        to Indians.
          (4) To provide a program that increases the skills 
        of, and provides continuing education to, nurses, nurse 
        midwives, and advanced practice nurses.
          (5) To provide any program that is designed to 
        achieve the purpose described in subsection (a).
    (c) Applications.--Each application for funding under 
subsection (a) shall include such information as the Secretary 
may require to establish the connection between the program of 
the applicant and a health care facility that primarily serves 
Indians.
    (d) Preferences for Grant Recipients.--In providing grants 
under subsection (a), the Secretary shall extend a preference 
to the following:
          (1) Programs that provide a preference to Indians.
          (2) Programs that train nurse midwives or advanced 
        practice nurses.
          (3) Programs that are interdisciplinary.
          (4) Programs that are conducted in cooperation with a 
        program for gifted and talented Indian students.
    (e) Quentin N. Burdick Program Grant.--
    The Secretary shall provide one of the grants authorized 
under subsection (a) [of this section] to establish and 
maintain a program at the University of North Dakota to be 
known as the [``] `Quentin N. Burdick American Indians Into 
Nursing Program' ['']. Such program shall, to the maximum 
extent feasible, coordinate with the Quentin N. Burdick Indian 
Health Programs established under section 117(b) [1616g(b) of 
this title] and the Quentin N. Burdick American Indians 
IntoPsychology Program established under section 105(b) [1621p(b) of 
this title].
    (f) Active Duty Service O[o]bligation.--
    The active duty service obligation prescribed under section 
338C of the Public Health Service Act (42 U.S.C. 254m) [of 
Title 42] shall be met by each individual who receives training 
or assistance described in paragraph (1) or (2) of subsection 
(b) [of this section] that is funded by a grant provided under 
subsection (a) [of this section]. Such obligation shall be met 
by service--
          (1) [(A)] in the [Indian Health] Service;
          (2) [(B)] in a program of an Indian Tribe or Tribal 
        Organization conducted under the Indian Self-
        Determination and Education Assistance Act (including 
        programs under agreements with the Bureau of Indian 
        Affairs) [a contract entered into under the Indian 
        Self-Determination Act [25 U.S.C.A. Sec. 450f et 
        seq.]];
          (3)[(C)] in a program assisted under title V 
        [subchapter IV] of this Act [chapter]; or
          (4) [(D)]1 in the private practice of nursing if, as 
        determined by the Secretary, in accordance with 
        guidelines promulgated by the Secretary, such practice 
        is situated in a physician or other health 
        [professional] shortage area and addresses the health 
        care needs of a substantial number of Indians.
    [(g) Authorization of appropriations
    [Beginning with fiscal year 1993, of the amounts 
appropriated under the authority of this subchapter for each 
fiscal year to be used to carry out this section, not less than 
$1,000,000 shall be used to provide grants under subsection (a) 
of this section for the training of nurse midwives, nurse 
anesthetists, and nurse practitioners.

[Sec. 1616e-1. Nursing school clinics

    [(a) Grants
    [In addition to the authority of the Secretary under 
section 1616e(a)(1) of this title, the Secretary, acting 
through the Service, is authorized to provide grants to public 
or private schools of nursing for the purpose of establishing, 
developing, operating, and administering clinics to address the 
health care needs of Indians, and to provide primary health 
care services to Indians who reside on or within 50 miles of 
Indian country, as defined in section 1151 of Title 18.
    [(b) Purposes
    [Grants provided under subsection (a) of this section may 
be used to--
          [(1) establish clinics, to be run and staffed by the 
        faculty and students of a grantee school, to provide 
        primary care services in areas in or within 50 miles of 
        Indian country (as defined in section 1151 of Title 
        18);]
          [(2) provide clinical training, program development, 
        faculty enhancement, and student scholarships in a 
        manner that would benefit such clinics; and
          [(3) carry out any other activities determined 
        appropriate by the Secretary.
    [(c) Amount and conditions
    [The Secretary may award grants under this section in such 
amounts and subject to such conditions as the Secretary deems 
appropriate.
    [(d) Design
    [The clinics established under this section shall be 
designed to provide nursing students with a structured clinical 
experience that is similar in nature to that provided by 
residency training programs for physicians.
    [(e) Regulations
    [The Secretary shall prescribe such regulations as may be 
necessary to carry out the provisions of this section.
    [(f) Authorization to use amounts
    [Out of amounts appropriated to carry out this subchapter 
for each of the fiscal years 1993 through 2000 not more than 
$5,000,000 may be used to carry out this section.]

Sec. 1616f. Tribal Cultural Orientation. [culture and history]

    (a) Cultural Education of Employees.--[Program established]
    The Secretary, acting through the Service, shall 
requirethat [establish a program under which] appropriate employees of 
the Service who serve [particular] Indian [t]Tribes in each Service 
Area [shall] receive educational instruction in the history and culture 
of such Indian T[t]ribes and their relationship to [in the history of] 
the Service.
    (b) Program.--[Tribally-Controlled Community Colleges] In 
carrying out subsection (a), the Secretary shall establish a 
program which shall, to the extent feasible--
    [To the extent feasible, the program established under 
subsection (a) of this section shall--]
          (1) be developed in consultation with the affected 
        Indian Tribes, Tribal Organizations, and Urban Indian 
        Organizations; [be carried out through tribally-
        controlled community colleges (within the meaning of 
        section 1801(4) of this title) and tribally controlled 
        postsecondary vocational institutions (as defined in 
        section 2397h(2) of Title 20),]
          (2) be carried out through tribal colleges or 
        universities; [be developed in consultation with the 
        affected tribal government, and]
          (3) include instruction in American Indian [Native 
        American] studies; and[.]
          (4) describe the use and place of Traditional Health 
        Care Practices of the Indian Tribes in the Service 
        Area.

Sec. 1616g. INMED Program

    (a) Grants Authorized._
    The Secretary, acting through the Service, is authorized to 
provide grants to [at least 3] colleges and universities for 
the purpose of maintaining and expanding the Indian [Native 
American] health careers recruitment program known as the [``] 
`Indians into Medicine Program'[''] (hereinafter in this 
section referred to as [``] `INMED'['']) as a means of 
encouraging Indians to enter the health professions.
    (b) Quentin N. Burdick Grant.--[University of North Dakota]
    The Secretary shall provide one of the grants authorized 
under subsection (a) [of this section] to maintain the INMED 
program at the University of North Dakota, to be known as the 
`Quentin N. Burdick Indian Health Programs', unless the 
Secretary makes a determination, based upon program reviews, 
that the program is not meeting the purposes of this section. 
Such program shall, to the maximum extent feasible, coordinate 
with the Quentin N. Burdick American Indians Into Psychology 
Program established under section 105(b) [1621p(b) of this 
title] and the Quentin N. Burdick American Indians Into Nursing 
Program established under section 115 [1616e of this title].
    (c) Regulations.--[; Contents of recruitment program]
          [(1)] The Secretary, pursuant to this Act, shall 
        develop regulations to govern [for the competitive 
        awarding of the] grants pursuant to [provided under] 
        this section.
    (d) Requirements.--[(2)] Applicants for grants provided 
under this section shall agree to provide a program which--
          (1)[(A)] provides outreach and recruitment for health 
        professions to Indian communities, including 
        elementary[,] and secondary schools and community 
        colleges located on [Indian] reservations, which will 
        be served by the program[,];
          (2)[(B)] incorporates a program advisory board 
        comprised of representatives from the Indian tribes and 
        Indian communities which will be served by the 
        program[,];
          (3)[(C)] provides summer preparatory programs for 
        Indian students who need enrichment in the subjects of 
        math and science in order to pursue training in the 
        health professions[,];
          (4)[(D)] provides tutoring, counseling, and support 
        to students who are enrolled in a health career program 
        of study at the respective college or university[,]; 
        and
          (5)[(E)] to the maximum extent feasible, employs 
        qualified Indians in the program.
    [(d) Report to Congress
    [By no later than the date that is 3 years after November 
23, 1988, the Secretary shall submit a report to the Congress 
on the program established under this section including 
recommendations for expansion or changes to the program.]

Sec. 1616h. Health [t]Training [p]Programs of [c]Community [c]Colleges

    (a) Grants To Establish Programs._
          (1) In general.--The Secretary, acting through the 
        Service,shall award grants to accredited and accessible 
community colleges for the purpose of assisting such [the] community 
colleges in the establishment of programs which provide education in a 
health profession leading to a degree or diploma in a health profession 
for individuals who desire to practice such profession on or near a [an 
Indian] reservation or in an Indian Health Program [a tribal clinic].
          (2) Amount of grants._T[t]he amount of any grant 
        awarded to a community college under paragraph (1) for 
        the first year in which such a grant is provided to the 
        community college shall not exceed $100,000.
    (b) Grants for Maintenance and Recruiting.--[Eligibility]
          (1) In general.--The Secretary, acting through the 
        Service, shall award grants to accredited and 
        accessible community colleges that have established a 
        program described in subsection (a)(1) [of this 
        section] for the purpose of maintaining the program and 
        recruiting students for the program.
          (2) Requirements.--Grants may only be made under this 
        section to a community college which--
                  (A) is accredited[,];
                  (B) has a relationship with [access to] a 
                hospital facility, Service facility, or 
                hospital that could provide training of nurses 
                or health professionals[,];
                  (C) has entered into an agreement with an 
                accredited college or university medical 
                school, the terms of which--
                          (i) provide a program that enhances 
                        the transition and recruitment of 
                        students into advanced baccalaureate or 
                        graduate programs which train health 
                        professionals[,]; and
                          (ii) stipulate certifications 
                        necessary to approved internship and 
                        field placement opportunities at Indian 
                        Health Programs; [service unit 
                        facilities of the Service or at tribal 
                        health facilities,];
                  (D) has a qualified staff which has the 
                appropriate certifications[, and];
                  (E) is capable of obtaining State or regional 
                accreditation of the program described in 
                subsection (a)(1) [of this section.]; and
                  (F) agrees to provide for Indian preference 
                for applicants for programs under this section.
    (c) [Agreements and t]Technical [a]Assistance
    The Secretary shall encourage community colleges described 
in subsection (b)(2) [of this section] to establish and 
maintain programs described in subsection (a)(1) [of this 
section] by--
          (1) entering into agreements with such colleges for 
        the provision of qualified personnel of the Service to 
        teach courses of study in such programs[,]; and
          (2) providing technical assistance and support to 
        such colleges.
    (d) Advanced Training
          (1) Required._Any program receiving assistance under 
        this section that is conducted with respect to a health 
        profession shall also offer courses of study which 
        provide advanced training for any health professional 
        who--
                  (A)[(1)] has already received a degree or 
                diploma in such health profession[,]; and
                  (B)[(2)] provides clinical services on or 
                near a [an Indian] reservation or for an Indian 
                Health Program[, at a Service facility, or at a 
                tribal clinic].
          (2) May be offered at alternate site._Such courses of 
        study may be offered in conjunction with the college or 
        university with which the community college has entered 
        into the agreement required under subsection (b)(2)(C) 
        [of this section].
    (e) Funding Priority.--Where the requirements of subsection 
(b) are met, funding priority shall be provided to tribal 
colleges and universities in Service Areas where they exist.
    [(e) Definitions
    [For purposes of this section
          [(1) The term ``community college'' means--
                  [(A) a tribally controlled community college, 
                or
                  [(B) a junior or community college.
          [(2) The term ``tribally controlled community 
        college'' hasthe meaning given to such term by section 
1801(4) of this title.
          [(3) The term ``junior or community college'' has the 
        meaning given to such term by section 1058(e) of Title 
        20.

[Sec. 1616i. Additional incentives for health professionals

    [(a) Incentive special pay
    [The Secretary may provide the incentive special pay 
authorized under section 302(b) of Title 37, to civilian 
medical officers of the Indian Health Service who are assigned 
to, and serving in, positions included in the list established 
under subsection (b)(1) of this section for which recruitment 
or retention of personnel is difficult.
    [(b) List of positions; bonus pay
          [(1) the Secretary shall establish and update on an 
        annual basis a list of positions of health care 
        professionals employed by, or assigned to, the Service 
        for which recruitment or retention is difficult.
          [(2)(A) The Secretary may pay a bonus to any 
        commissioned officer or civil service employee, other 
        than a commissioned medical officer, dental officer, 
        optometrist, and veterinarian, who is employed in or 
        assigned to, and serving in, a position in the Service 
        included in the list established by the Secretary under 
        paragraph (1).
          [(B) The total amount of bonus payments made by the 
        Secretary under this paragraph to any employee during 
        any 1-year period shall not exceed $2,000.
    [(c) Work schedules
    [The Secretary may establish programs to allow the use of 
flexible work schedules, and compressed work schedules, in 
accordance with the provisions of subchapter II of chapter 61 
of Title 5, for health professionals employed by, or assigned 
to, the Service.]

Sec. 1616j. Retention bonus

    (a) Bonus Authorized.--[Eligibility]
    The Secretary may pay a retention bonus to any health 
professional [physician or nurse] employed by, or assigned to, 
and serving in, an Indian Health Program or Urban Indian 
Organization [the Service] either as a civilian employee or as 
a commissioned officer in the Regular or Reserve Corps of the 
Public Health Service who--
          (1) is assigned to, and serving in, a position 
        [included in the list established under section 
        1616i(b)(1) of this title] for which recruitment or 
        retention of personnel is difficult[,];
          (2) the Secretary determines is needed by Indian 
        Health Programs and Urban Indian Organizations; [the 
        Service,]
          (3) has--
                  (A) completed 3 years of employment with an 
                Indian Health Program or Urban Indian 
                Organization; [the Service,] or
                  (B) completed any service obligations 
                incurred as a requirement of--
                          (i) any Federal scholarship 
                        program[,]; or
                          (ii) any Federal education loan 
                        repayment program[,]; and
          (4) enters into an agreement with an Indian Health 
        Program or Urban Indian Organization [the Service] for 
        continued employment for a period of not less than 1 
        year.
    [(b) Minimum award percentage to nurses
    [Beginning with fiscal year 1993, not less than 25 percent 
of the retention bonuses awarded each year under subsection (a) 
of the section shall be awarded to nurses.]
    (b)[(c)] Rates.--[; maximum rate]
    The Secretary may establish rates for the retention bonus 
which shall provide for a higher annual rate for multiyear 
agreements than for single year agreements referred to in 
subsection (a)(4) [of this section], but in no event shall the 
annual rate be more than $25,000 per annum.
    [(d) Time of payment
    [The retention bonus for the entire period covered by the 
agreement described in subsection (a)(4) of this section shall 
be paid at the beginning of the agreed upon term of service.
    [(e) Refund; interest]
    (c) Default of Retention Agreement.--
    Any health professional [physician or nurse] failing to 
complete the agreed upon term of service, except where such 
failure is through no fault of the individual, shall be 
obligated to refund to the Government the full amount of the 
retention bonus for the period covered by the agreement, plus 
interest as determined by the Secretary in accordance with 
section 110(l)(2)(B) [1616a(l)(2)(B) of this title].
    (d) Other Retention Bonus.--
    [(f) Physicians and nurses employed under Indian Self-
Determination Act]
    The Secretary may pay a retention bonus to any health 
professional [physician or nurse] employed by a Tribal Health 
Program [an organization providing health care services to 
Indians pursuant to a contract under the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et. Seq.]] if such 
health professional [physician or nurse] is serving in a 
position which the Secretary determines is--
          (1) a position for which recruitment or retention is 
        difficult; and
          (2) necessary for providing health care services to 
        Indians.

Sec. 1616k. Nursing residency program

    (a) Establishment of Program.--
    The Secretary, acting through the Service, shall establish 
a program to enable Indians who are licensed practical nurses, 
licensed vocational nurses, and registered nurses who are 
working in an Indian H[h]ealth P[p]rogram or Urban Indian 
Organization [(as defined in section 1616a(a)(2)(A) of this 
title)], and have done so for a period of not less than 1 [one] 
year, to pursue advanced training.
    [(b) Program components]
    Such program shall include a combination of education and 
work study in an Indian H[h]ealth P[p]rogram or Urban Indian 
Organization [(as defined in section 1616a(a)(2)(A) of this 
title)] leading to an associate or bachelor's degree (in the 
case of a licensed practical nurse or licensed vocational 
nurse), [or] a bachelor's degree (in the case of a registered 
nurse) or advanced degrees or certification in nursing and 
public health [a Master's degree].
    (b)[(c)] Service O[o]bligation.--[of program participant]
    An individual who participates in a program under 
subsection (a) [of this section], where the educational costs 
are paid by the Service, shall incur an obligation to serve in 
an Indian H[h]ealth P[p]rogram or Urban Indian Organization for 
a period of obligated service equal to the amount of [at least 
three times the period of the] time during which the individual 
participates in such program. In the event that the individual 
fails to complete such obligated service, the United States 
shall be entitled to recover from such individual an amount 
determined in accordance with the formula specified in 
subsection (l) of section 110 [1616a of this title] in the 
manner provided for in such subsection.

Sec. 1616l. Community Health Aide Program for Alaska

    (a) General Purposes [Maintenance] of Program.--
    Under the authority of the Act of November 2, 1921 (25 
U.S.C. 13)(commonly known as the `Snyder Act') [section 13 of 
this title], the Secretary, acting through the Service, shall 
develop and operate [maintain] a Community Health Aide Program 
in Alaska under which the Service--
          (1) provides for the training of Alaska Natives as 
        health aides or community health practitioners;
          (2) uses such aides or practitioners in the provision 
        of health care, health promotion, and disease 
        prevention services to Alaska Natives living in 
        villages in rural Alaska; and
          (3) provides for the establishment of 
        teleconferencing capacity in health clinics located in 
        or near such villages for use by community health aides 
        or community health practitioners.
    (b) Specific Program Requirements.--[Training; curriculum; 
certification board]
    The Secretary, acting through the Community Health Aide 
Program of the Service, shall--
          (1) using trainers accredited by the Program, provide 
        a high standard of training to community health aides 
        and community health practitioners to ensure that such 
        aides and practitioners provide quality health care, 
        health promotion, and disease prevention services to 
        the villages served by theProgram;
          (2) in order to provide such training, develop a 
        curriculum that--
                  (A) combines education in the theory of 
                health care with supervised practical 
                experience in the provision of health care;
                  (B) provides instruction and practical 
                experience in the provision of acute care, 
                emergency care, health promotion, disease 
                prevention, and the efficient and effective 
                management of clinic pharmacies, supplies, 
                equipment, and facilities; and
                  (C) promotes the achievement of the health 
                status objectives specified in section 3(2) 
                [1602(b) of this title];
          (3) establish and maintain a Community Health Aide 
        Certification Board to certify as community health 
        aides or community health practitioners individuals who 
        have successfully completed the training described in 
        paragraph (1) or can demonstrate equivalent experience;
          (4) develop and maintain a system which identifies 
        the needs of community health aides and community 
        health practitioners for continuing education in the 
        provision of health care, including the areas described 
        in paragraph (2)(B), and develop programs that meet the 
        needs for such continuing education;
          (5) develop and maintain a system that provides close 
        supervision of community health aides and community 
        health practitioners; and
          (6) develop a system under which the work of 
        community health aides and community health 
        practitioners is reviewed and evaluated to assure the 
        provision of quality health care, health promotion, and 
        disease prevention services.
    (c) National Community Health Aide Program.--The Secretary, 
acting through the Service, shall develop and promulgate 
regulations to operate a national Community Health Aide Program 
consistent with the requirements of this section without 
reducing funds for the Community Health Aide Program for 
Alaska.

[Sec. 1616m. Matching grants to tribes for scholarship programs

    [(a) In general
          [(1) The Secretary shall make grants to Indian tribes 
        and tribal organizations for the purpose of assisting 
        such tribes and tribal organizations in educating 
        Indians to serve as health professionals in Indian 
        communities.
          [(2) Amounts available for grants under paragraph (1) 
        for any fiscal year shall not exceed 5 percent of 
        amounts available for such fiscal year for Indian 
        Health Scholarships under section 1613a of this title.
          [(3) An application for a grant under paragraph (1) 
        shall be in such form and contain such agreements, 
        assurances, and information as the Secretary determines 
        are necessary to carry out this section.
    [(b) Compliance with requirements
          [(1) An Indian tribe or tribal organization receiving 
        a grant under subsection (a) of this section shall 
        agree to provide scholarships to Indians pursuing 
        education in the health professions in accordance with 
        the requirements of this section.
          [(2) With respect to the costs of providing any 
        scholarship pursuant to paragraph (1)--
                  [(A) 80 percent of the costs of the 
                scholarship shall be paid from the grant made 
                under subsection (a) of this section to the 
                Indian tribe or tribal organization; and
                  [(B) 20 percent of such costs shall be paid 
                from non-Federal contributions by the Indian 
                tribe or tribal organization through which the 
                scholarship is provided.
          [(3) In determining the amount of non-Federal 
        contributions that have been provided for purposes of 
        subparagraph (B) of paragraph (2), any amounts provided 
        by the Federal Government to the Indian tribe or tribal 
        organization involved or to any other entity shall not 
        be included.
          [(4) Non-Federal contributions required by 
        subparagraph (B) of paragraph (2) may be provided 
        directly by the Indian tribe or tribal organization 
        involved or through donations from public and private 
        entities.
    [(c) Course of study in health professions
    [An Indian tribe or tribal organization shall provide 
scholarships under subsection (b) of this section only to 
Indians enrolled or accepted for enrollment in the course of 
study (approved by the Secretary) in one of the 
healthprofessions described in section 1613a(a) of this title.
    [(d) Contract requirements
    [In providing scholarships under subsection (b) of this 
section, the Secretary and the Indian tribe or tribal 
organization shall enter into a written contract with each 
recipient of such scholarship. Such contract shall--
          [(1) obligate such recipient to provide service in an 
        Indian health program (as defined in section 
        1616a(a)(2)(A) of this title), in the same service area 
        where the Indian tribe or tribal organization providing 
        the scholarship is located, for--
                  [(A) a number of years equal to the number of 
                years for which the scholarship is provided (or 
                the part-time equivalent thereof, as determined 
                by the Secretary), or for a period of 2 years, 
                whichever period is greater; or
                  [(B) such greater period of time as the 
                recipient and the Indian tribe or tribal 
                organization may agree;
          [(2) provide that the amount of such scholarship--
                  [(A) may be expended only for--
                          [(i) tuition expenses, other 
                        reasonable educational expenses, and 
                        reasonable living expenses incurred in 
                        attendance at the educational 
                        institution; and
                          [(ii) payment to the recipient of a 
                        monthly stipend of not more than the 
                        amount authorized by section 
                        254l(g)(1)(B) of Title 42, such amount 
                        to be reduced pro rata (as determined 
                        by the Secretary) based on the number 
                        of hours such student is enrolled; and
                  [(B) may not exceed, for any year of 
                attendance for which the scholarship is 
                provided, the total amount required for the 
                year for the purposes authorized in 
                subparagraph (A);
          [(3) require the recipient of such scholarship to 
        maintain an acceptable level of academic standing (as 
        determined by the educational institution in accordance 
        with regulations issued by the Secretary); and
          [(4) require the recipient of such scholarship to 
        meet the educational and licensure requirements 
        necessary to be a physician, certified nurse 
        practitioner, certified nurse midwife, or physician 
        assistant.
    [(e) Breach of contract
          [(1) an individual who has entered into a written 
        contract with the Secretary and an Indian tribe or 
        tribal organization under subsection (d) of this 
        section and who--
                  [(A) fails to maintain an acceptable level of 
                academic standing in the educational 
                institution in which he is enrolled (such level 
                determined by the educational institution under 
                regulations of the Secretary),
                  [(B) is dismissed from such educational 
                institution for disciplinary reasons,
                  [(C) voluntarily terminates the training in 
                such an educational institution for which he is 
                provided a scholarship under such contract 
                before the completion of such training, or
                  [(D) fails to accept payment, or instructs 
                the educational institution in which he is 
                enrolled not to accept payment,
in whole or in part, of a scholarship under such contract, in 
lieu of any service obligation arising under such contract, 
shall be liable to the United States for the Federal share of 
the amount which has been paid to him, or on his behalf, under 
the contract.
          [(2) If for any reason not specified in paragraph 
        (1), an individual breaches his written contract by 
        failing either to begin such individual's service 
        obligation required under such contract or to complete 
        such service obligation, the United States shall be 
        entitled to recover from the individual an amount 
        determined in accordance with the formula specified in 
        subsection (l) of section 1616a of this title in the 
        manner provided for in such subsection.
          [(3) The Secretary may carry out this subsection on 
        the basis of information submitted by the tribes or 
        tribal organization involved, or on the basis of 
        information collected through such other means as the 
        Secretary determines to be appropriate.
    [(f) Nondiscriminatory practice
    [The recipient of a scholarship under subsection (b) of 
this section shall agree, in providing health care pursuant to 
the requirements of subsection (d)(1) of this section--
          [(1) not to discriminate against an individual 
        seeking suchcare on the basis of the ability of the 
individual to pay for such care or on the basis that payment for such 
care will be made pursuant to the program established in title XVIII of 
the Social Security Act [42 U.S.C.A. Sec. 1395 et. Seq.] or pursuant to 
the program established in title XIX of such Act [42 U.S.C.A. Sec. 1396 
et. seq.]; and
          [(2) to accept assignment under section 
        1842(b)(3)(B)(ii) of the Social Security Act [42 
        U.S.C.A. Sec. 1395u(b)(3)(B)(ii)] for all services for 
        which payment may be made under part B of title XVIII 
        of such Act [42 U.S.C.A. Sec. 1395j et. seq.], and to 
        enter into an appropriate agreement with the State 
        agency that administers the State plan for medical 
        assistance under title XIX of such Act [42 U.S.C.A. 
        Sec. 1396 et. seq.] to provide service to individuals 
        entitled to medical assistance under the plan.
    [(g) Payments for subsequent fiscal years
    [The Secretary may not make any payments under subsection 
(a) of this section to an Indian tribe or tribal organization 
for any fiscal year subsequent to the first fiscal year of such 
payments unless the Secretary determines that, for the 
immediately preceding fiscal year, the Indian tribe or tribal 
organization has complied with requirements of this section.]

Sec. 1616n. Tribal H[h]ealth P[p]rogram A[a]dministration

    The Secretary, acting through the Service, shall, by 
funding agreement [contract] or otherwise, provide training for 
Indians [individuals] in the administration and planning of 
T[t]ribal H[h]ealth P[p]rograms.

Sec. 123. Health Professional Chronic Shortage Demonstration Programs

    (a) Demonstration Programs Authorized.--The Secretary, 
acting through the Service, may fund demonstration programs for 
Tribal Health Programs to address the chronic shortages of 
health professionals.
    (b) Purposes of Programs.--The purposes of demonstration 
programs funded under subsection (a) shall be--
          (1) to provide direct clinical and practical 
        experience at a Service Unit to health profession 
        students and residents from medical schools;
          (2) to improve the quality of health care for Indians 
        by assuring access to qualified health care 
        professionals; and
          (3) to provide academic and scholarly opportunities 
        for health professionals serving Indians by identifying 
        all academic and scholarly resources of the region.
    (c) Advisory Board.--The demonstration programs established 
pursuant to subsection (a) shall incorporate a program advisory 
board composed of representatives from the Indian Tribes and 
Indian communities in the area which will be served by the 
program.

Sec. 124. Treatment of Scholarships for Certain Purposes

    Scholarships provided to individuals pursuant to this title 
shall be deemed `qualified Scholarships' for purposes of 
section 11 of the Internal Revenue Code of 1986.

Sec. 125. National Health Service Corps

    (a) No Reduction in Services.--The Secretary shall not--
          (1) remove a member of the National Health Service 
        Corps from an Indian Health Program or Urban Indian 
        Organization; or
          (2) withdraw funding used to support such member;
unless the Secretary, acting through the Service, Indian 
Tribes, or Tribal Organizations, has ensured that the Indians 
receiving services from such member will experience no 
reduction in services.
    (b) Exemption From Limitations.--National Health Service 
Corps scholars qualifying for the Commissioned Corps in the 
United States Public Health Service shall be exempt from the 
full-time equivalent limitations of the National Health Service 
Corps and the Service when serving as a commissioned corps 
officer in a Tribal Health Program or an Urban Indian 
Organization.

Sec. 126. Substance Abuse Counselor Educational Curricula Demonstration 
                    Programs

    (a) Grants and Contracts.--The Secretary, acting through 
the Service, may enter into contracts with, or make grants to, 
accredited tribal colleges and universities and eligible 
accredited and accessible community colleges to establish 
demonstration programs to develop educational curricula for 
substance abuse counseling.
    (b) Use of Funds.--Funds provided under this section shall 
be used only for developing and providing educational 
curriculumfor substance abuse counseling (including paying 
salaries for instructors). Such curricula may be provided through 
satellite campus programs.
    (c) Time Period of Assistance; Renewal.--A contract entered 
into or a grant provided under this section shall be for a 
period of 1 year. Such contract or grant may be renewed for an 
additional 1-year period upon the approval of the Secretary.
    (d) Criteria for Review and Approval of Applications.--Not 
later than 180 days after the date of the enactment of the 
Indian Health Care Improvement Act Amendments of 2004, the 
Secretary, after consultation with Indian Tribes and 
administrators of tribal colleges and universities and eligible 
accredited and accessible community colleges, shall develop and 
issue criteria for the review and approval of applications for 
funding (including applications for renewals of funding) under 
this section. Such criteria shall ensure that demonstration 
programs established under this section promote the development 
of the capacity of such entities to educate substance abuse 
counselors.
    (e) Assistance.--The Secretary shall provide such technical 
and other assistance as may be necessary to enable grant 
recipients to comply with the provisions of this section.
    (f) Report.--Each fiscal year, the Secretary shall submit 
to the President, for inclusion in the report which is required 
to be submitted under section 801 for that fiscal year, a 
report on the findings and conclusions derived from the 
demonstration programs conducted under this section during that 
fiscal year.
    (g) Definition.--For the purposes of this section, the term 
'educational curriculum' means 1 or more of the following:
          (1) Classroom education.
          (2) Clinical work experience.
          (3) Continuing education workshops.

Sec. 127. Behavioral Health Training and Community Education Programs

    (a) Study; List.--The Secretary, acting through the 
Service, and the Secretary of the Interior, in consultation 
with Indian Tribes and Tribal Organizations, shall conduct a 
study and compile a list of the types of staff positions 
specified in subsection (b) whose qualifications include, or 
should include, training in the identification, prevention, 
education, referral, or treatment of mental illness, or 
dysfunctional and self destructive behavior.
    (b) Positions.--The positions referred to in subsection (a) 
are--
          (1) staff positions within the Bureau of Indian 
        Affairs, including existing positions, in the fields 
        of--
                  (A) elementary and secondary education;
                  (B) social services and family and child 
                welfare;
                  (C) law enforcement and judicial services; 
                and
                  (D) alcohol and substance abuse;
          (2) staff positions within the Service; and
          (3) staff positions similar to those identified in 
        paragraphs (1) and (2) established and maintained by 
        Indian Tribes, Tribal Organizations, (without regard to 
        the funding source) and Urban Indian Organizations.
    (c) Training Criteria.--
          (1) In general.--The appropriate Secretary shall 
        provide training criteria appropriate to each type of 
        position identified in subsection (b)(1) and (b)(2) and 
        ensure that appropriate training has been, or shall be 
        provided to any individual in any such position. With 
        respect to any such individual in a position identified 
        pursuant to subsection (b)(3), the respective 
        Secretaries shall provide appropriate training to, or 
        provide funds to, an Indian Tribe, Tribal Organization, 
        or Urban Indian Organization for training of 
        appropriate individuals. In the case of positions 
        funded under a funding agreement, the appropriate 
        Secretary shall ensure that funds to cover the costs of 
        such training costs are included in the funding 
        agreement.
          (2) Position specific training criteria.--Position 
        specific training criteria shall be culturally relevant 
        to Indians and Indian Tribes and shall ensure that 
        appropriate information regarding Traditional Health 
        Care Practices is provided.
    (d) Community Education on Mental Illness.--The Service 
shall develop and implement, on request of an Indian Tribe, 
Tribal Organization, or Urban Indian Organization, or assist 
the Indian Tribe, Tribal Organization, or Urban Indian 
Organization todevelop and implement, a program of community 
education on mental illness. In carrying out this subsection, the 
Service shall, upon request of an Indian Tribe, Tribal Organization, or 
Urban Indian Organization, provide technical assistance to the Indian 
Tribe, Tribal Organization, or Urban Indian Organization to obtain and 
develop community educational materials on the identification, 
prevention, referral, and treatment of mental illness and dysfunctional 
and self-destructive behavior.
    (e) Plan.--Not later than 90 days after the date of the 
enactment of the Indian Health Care Improvement Act Amendments 
of 2004, the Secretary shall develop a plan under which the 
Service will increase the health care staff providing 
behavioral health services by at least 500 positions within 5 
years after the date of the enactment of this section, with at 
least 200 of such positions devoted to child, adolescent, and 
family services. The plan developed under this subsection shall 
be implemented under the Act of November 2, 1921 (25 U.S.C. 13) 
(commonly known as the `Snyder Act').

[Sec. 1616o. University of South Dakota pilot program

    [(a) Establishment
    [The Secretary may make a grant to the School of Medicine 
of the University of South Dakota (hereafter in this section 
referred to as ``USDSM'') to establish a pilot program on an 
Indian reservation at one or more service units in South Dakota 
to address the chronic manpower shortage in the Aberdeen Area 
of the Service.
    [(b) Purposes
    [The purposes of the program established pursuant to a 
grant provided under subsection (a) of this section are--
          [(1) to provide direct clinical and practical 
        experience at the service unit to medical students and 
        residents from USDSM and other medical schools;
          [(2) to improve the quality of health care for 
        Indians by assuring access to qualified health care 
        professionals; and
          [(3) to provide academic and scholarly opportunities 
        for physicians, physician assistants, nurse 
        practitioners, nurse, and other allied health 
        professionals serving Indian people by identifying and 
        utilizing all academic and scholarly resources of the 
        region.
    [(c) Composition; designation
    [The pilot program established pursuant to a grant provided 
under subsection (a) of this section shall--
          [(1) incorporate a program advisory board composed of 
        representatives from the tribes and communities in the 
        area which will be served by the program; and
          [(2) shall be designated as an extension of the USDSM 
        campus and program participants shall be under the 
        direct supervision and instruction of qualified medical 
        staff serving at the service unit who shall be members 
        of the USDSM faculty.
    [(d) Coordination with other schools
    [The USDSM shall coordinate the program established 
pursuant to a grant provided under subsection (a) of this 
section with other medical schools in the region, nursing 
schools, tribal community colleges, and other health 
professional schools.
    [(e) Development of additional professional opportunities
    [The USDSM, in cooperation with the Service, shall develop 
additional professional opportunities for program participants 
on Indian reservations in order to improve the recruitment and 
retention of qualified health professionals in the Aberdeen 
Area of the Service.]

Sec. 1616p. Authorization of [a]Appropriations

    There are authorized to be appropriated such sums as may be 
necessary for each fiscal year through fiscal year 2015 [2000] 
to carry out this title [subchapter].

                 TITLE [SUBCHAPTER] II--HEALTH SERVICES

Sec. 1621. Indian Health Care Improvement Fund

    (a) Use of Funds.--[Approved expenditures]
    The Secretary, acting through the Service, is authorized to 
expend funds, directly or under the authority of the Indian 
Self-Determination and Education Assistance Act, which are 
appropriated under the authority of this section, [through the 
Service,] for the purposes of--
          (1) eliminating the deficiencies in health status and 
        health resources of all Indian [t]Tribes[,];
          (2) eliminating backlogs in the provision of health 
        care services to Indians[,];
          (3) meeting the health needs of Indians in an 
        efficient and equitable manner, including the use of 
        telehealth and telemedicine when appropriate; [and]
          (4) eliminating inequities in funding for both direct 
        care and contract health service programs; and
          (5)[(4)] augmenting the ability of the Service to 
        meet the following health service responsibilities[, 
        either through direct or contract care or through 
        contracts entered into pursuant to the Indian Self-
        Determination Act [25 U.S.C.A. Sec. 450f et seq.],] 
        with respect to those Indian [t]Tribes with the highest 
        levels of health status deficiencies and resource 
        deficiencies:
                  (A) [c]Clinical care, [(direct and indirect)] 
                including, but not limited to, inpatient care, 
                outpatient care (including audiology, clinical 
                eye and vision care), primary care, secondary 
                and tertiary care, and long-term care.[;]
                  (B) [p]Preventive health, including 
                [screening] mammography and other cancer 
                screening in accordance with section 207. 
                [1621k of this title;]
                  (C) [d]Dental care. [(direct and indirect);]
                  (D) [m]Mental health, including community 
                mental health services, inpatient mental health 
                services, dormitory mental health services, 
                therapeutic and residential treatment centers, 
                and training of traditional health care 
                [Indian] practitioners.[;]
                  (E) [e]Emergency medical services.[;]
                  (F) [t]Treatment and control of, and 
                rehabilitative care related to, alcoholism and 
                drug abuse (including fetal alcohol syndrome) 
                among Indians.[;]
                  (G) [a]Accident prevention programs.[;]
                  (H) [h]Home health care.[;]
                  (I) [c]Community health representatives.[; 
                and]
                  (J) [m]Maintenance and repair.
                  (K) Traditional Health Care Practices.
    (b) No Offset or Limitation.--[Effect on other 
appropriations; allocation to service units]
          [(1)] Any funds appropriated under the authority of 
        this section shall not be used to offset or limit any 
        other appropriations made to the Service under this Act 
        or the Act of November 2, 1921 (25 U.S.C. 13) (commonly 
        known as the `Snyder Act'), [section 13 of this title,] 
        or any other provision of law.
    (c) Allocation; Use.--[(2)(A)]
          (1) In general.--Funds appropriated under the 
        authority of this section shall [may] be allocated to 
        Service Units, Indian Tribes, or Tribal Organizations 
        [on a service unit basis]. The funds allocated to each 
        Indian Tribe, Tribal Organization, or S[s]ervice 
        U[u]nit under this [sub]paragraph shall be used by the 
        Indian Tribe, Tribal Organization, or S[s]ervice 
        U[u]nit under this paragraph to improve [reduce] the 
        health status and reduce the resource deficiency of 
        each Indian tribe served by such S[s]ervice U[u]nit, 
        Indian Tribe, or Tribal Organization.
          (2)[(B)] Apportionment of allocated funds.--The 
        apportionment of funds allocated to a S[s]ervice 
        U[u]nit, Indian Tribe, or Tribal Organization under 
        [sub]paragraph (1)[(A)] among the health service 
        responsibilities described in subsection (a)(5)[(4) of 
        this section] shall be determined by the Service in 
        consultation with, and with the active participation 
        of, the affected Indian tribes and Tribal 
        Organizations.
    (d)[(c)] Provisions Relating to Health Status and 
R[r]esource[s d]Deficienc[y]ies [levels]
    For purposes of this section, the following definitions 
apply:[--]
          (1) Definition.--The term [``]`health status and 
        resource deficiency'[''] means the extent to which--
                  (A) the health status objectives set forth in 
                section 3(2)[1602(b) of this title] are not 
                being achieved; and
                  (B) the Indian [t]Tribe or Tribal 
                Organization does not have available to it the 
                health resources it needs, taking into account 
                the actual cost of providing health care 
                services given local geographic, climatic, 
                rural, or other circumstances.
          (2) Available resources.--The health resources 
        available toan Indian [t]Tribe or Tribal Organization 
include health resources provided by the Service as well as health 
resources used by the Indian [t]Tribe or Tribal Organization, including 
services and financing systems provided by any Federal programs, 
private insurance, and programs of State or local governments.
          (3) Process for review of determinations.--The 
        Secretary shall establish procedures which allow any 
        Indian [t]Tribe or Tribal Organization to petition the 
        Secretary for a review of any determination of the 
        extent of the health status and resource deficiency of 
        such Indian T[t]ribe or Tribal Organization.
    (e)[(d)] Eligibility for Funds.--[Programs administered by 
Indian tribe]
          [(1)] Tribal Health Programs [administered by any 
        Indian tribe or tribal organization under the authority 
        of the Indian Self-Determination Act] shall be eligible 
        for funds appropriated under the authority of this 
        section on an equal basis with programs that are 
        administered directly by the Service.
          [(2) If any funds allocated to a tribe or service 
        unit under the authority of this section are used for a 
        contract entered into under the Indian Self-
        Determination Act [25 U.S.C.A. Sec. 450f et seq.], a 
        reasonable portion of such funds may be used for health 
        planning, training, technical assistance, and other 
        administrative support functions.]
    (f)[(e)] Report [to Congress].--
    By no later than the date that is 3 years after the date of 
the enactment of the Indian Health Care Improvement Act 
Amendments of 2004 [October 29, 1992], the Secretary shall 
submit to [the] Congress the current health status and resource 
deficiency report of the Service for each [Indian tribe or 
s]Service [u]Unit, including newly recognized or acknowledged 
Indian T[t]ribes. Such report shall set out--
          (1) the methodology then in use by the Service for 
        determining [t]Tribal health status and resource 
        deficiencies, as well as the most recent application of 
        that methodology;
          (2) the extent of the health status and resource 
        deficiency of each Indian tribe served by the Service 
        or a Tribal Health Program;
          (3) the amount of funds necessary to eliminate the 
        health status and resource deficiencies of all Indian 
        tribes served by the Service or a Tribal Health 
        Program; and
          (4) an estimate of--
                  (A) the amount of health service funds 
                appropriated under the authority of this Act 
                [chapter], or any other Act, including the 
                amount of any funds transferred to the 
                Service[,] for the preceding fiscal year which 
                is allocated to each S[s]ervice U[u]nit, Indian 
                [t]Tribe, or Tribal Organization [comparable 
                entity];
                  (B) the number of Indians eligible for health 
                services in each [s]Service [u]Unit or Indian 
                [t]Tribe or Tribal Organization; and
                  (C) the number of Indians using the Service 
                resources made available to each [s]Service 
                [u]Unit, [or] Indian [t]Tribe or Tribal 
                Organization, and, to the extent available, 
                information on the waiting lists and number of 
                Indians turned away for services due to lack of 
                resources.
    (g)[(f)] Inclusion [Appropriated funds included] in [b]Base 
[b]Budget [of Service].--
    Funds appropriated under [authority of] this section for 
any fiscal year shall be included in the base budget of the 
Service for the purpose of determining appropriations under 
this section in subsequent fiscal years.
    (h)[(g)] Clarification.--[Continuation of Service 
responsibilities for backlogs and parity]
    Nothing in this section is intended to diminish the primary 
responsibility of the Service to eliminate existing backlogs in 
unmet health care needs, nor are the provisions of this section 
intended to discourage the Service from undertaking additional 
efforts to achieve equity [parity] among Indian[s t]Tribes and 
Tribal Organizations.
    (i)[(h)] Funding Designation.--[Authorization of 
appropriations]
    Any funds appropriated under the authority of this section 
shall be designated as the [``]`Indian Health Care Improvement 
Fund'[''].

Sec. 1621a. Catastrophic [h]Health [e]Emergency [f]Fund

    (a) Establishment.--[; administration; purpose]
          [(1)] There is hereby established an Indian 
        Catastrophic Health Emergency Fund (hereafter in this 
        section referred to as the `CHEF' [``Fund'']) 
        consisting of--
          (1)[(A)] the amounts deposited under subsection 
        (f)[(d) of this section,]; and
          (2)[(B)] the amounts appropriated to CHEF [the Fund] 
        under this section.
    (b) Administration.--[(2) The Fund] CHEF shall be 
administered by the Secretary, acting through the central 
office of the Service, solely for the purpose of meeting the 
extraordinary medical costs associated with the treatment of 
victims of disasters or catastrophic illnesses who are within 
the responsibility of the Service.
          [(3) The Fund shall not be allocated, apportioned, or 
        delegated on a service unit, area office, or any other 
        basis.]
    (c) Conditions on Use of Fund.--[(4)] No part of CHEF [the 
Fund] or its administration shall be subject to contract or 
grant under any law, including the Indian Self-Determination 
and Education Assistance Act,[ [25 U.S.C.A. Sec. 450f et 
seq.].] nor shall CHEF funds be allocated, apportioned, or 
delegated on an Area Office, Service Unit, or other similar 
basis.
    (d)[(b)] Regulations.--[; procedures for payment]
    The Secretary shall, through the negotiated rulemaking 
process under title VIII, promulgate [promulgation of] 
regulations consistent with the provisions of this section to--
          (1) establish a definition of disasters and 
        catastrophic illnesses for which the cost of the 
        treatment provided under contract would qualify for 
        payment from CHEF [the Fund];
          (2) provide that a [s]Service [u]Unit shall not be 
        eligible for reimbursement for the cost of treatment 
        from CHEF [the Fund] until its cost of treating any 
        victim of such catastrophic illness or disaster has 
        reached a certain threshold cost which the Secretary 
        shall establish at--
                  (A) the 2000 level of $19,000 [for 1993, not 
                less than $15,000 or not more than $25,000]; 
                and
                  (B) for any subsequent year, not less than 
                the threshold cost of the previous year 
                increased by the percentage increase in the 
                medical care expenditure category of the 
                consumer price index for all urban consumers 
                (United States city average) for the 12-month 
                period ending with December of the previous 
                year;
          (3) establish a procedure for the reimbursement of 
        the portion of the costs that exceeds such threshold 
        cost incurred by--
                  (A) [s]Service [u]Units; [or facilities of 
                the Service,] or
                  (B) whenever otherwise authorized by the 
                Service, non-Service facilities or providers[, 
                in rendering treatment that exceeds such 
                threshold cost];
          (4) establish a procedure for payment from CHEF [the 
        Fund] in cases in which the exigencies of the medical 
        circumstances warrant treatment prior to the 
        authorization of such treatment by the Service; and
          (5) establish a procedure that will ensure that no 
        payment shall be made from CHEF [the Fund] to any 
        provider of treatment to the extent that such provider 
        is eligible to receive payment for the treatment from 
        any other Federal, State, local, or private source of 
        reimbursement for which the patient is eligible.
    (e) No Offset or Limitation.--[(c) Effect on other 
appropriations]
    Amounts appropriated to CHEF [the Fund] under this section 
shall not be used to offset or limit appropriations made to the 
Service under authority of the Act of November 2, 1921 (25 
U.S.C. 13) (commonly known as the `Snyder Act') [section 13 of 
this title], or any other law.
    (f)[(d)] Deposit of Reimbursement[s to] Funds.--
    There shall be deposited into CHEF [the Fund] all 
reimbursements to which the Service is entitled from any 
Federal, State, local, or private source (including third party 
insurance) by reason of treatment rendered to any victim of a 
disaster or catastrophic illness the cost of which was paid 
from CHEF [the Fund].

Sec. 1621b. Health [p]Promotion and [d]Disease [p]Prevention 
                    [s]Services

    (a) Findings.--Congress finds that health promotion and 
disease prevention activities--
          (1) improve the health and well-being of Indians; and
          (2) reduce the expenses for health care of Indians.
    [(a) Authorization]
    (b) Provision of Services.--
    The Secretary, acting through the Service and Tribal Health 
Programs, shall provide health promotion and disease prevention 
services to Indians [so as] to achieve the health status 
objectives set forth in section 3(2)[1602(b) of this title].
    (c)[(b)] Evaluation.--[Statement for Presidential Budget]
    The Secretary, after obtaining input from the affected 
Tribal Health Programs, shall submit to the President for 
inclusion in each report [statement] which is required to be 
submitted to [the] Congress under section 801[1671 of this 
title] an evaluation of--
          (1) the health promotion and disease prevention needs 
        of Indians[,];
          (2) the health promotion and disease prevention 
        activities which would best meet such needs[,];
          (3) the internal capacity of the Service and Tribal 
        Health Programs to meet such needs[,]; and
          (4) the resources which would be required to enable 
        the Service and Tribal Health Programs to undertake the 
        health promotion and disease prevention activities 
        necessary to meet such needs.

Sec. 1621c. Diabetes [p]Prevention, [t]Treatment, and [c]Control

    (a) Determinations Regarding Diabetes.--[Incidence and 
complications]
    The Secretary, acting through the Service, and in 
consultation with [the] Indian T[t]ribes and Tribal 
Organizations, shall determine--
          (1) by an Indian T[t]ribe, Tribal Organization, and 
        by Service [u]Unit [of the Service], the incidence of, 
        and the types of complications resulting from, diabetes 
        among Indians; and
          (2) based on the determinations made pursuant to 
        paragraph (1), the measures (including patient 
        education and effective ongoing monitoring of disease 
        indicators) each Service [u]Unit should take to reduce 
        the incidence of, and prevent, treat, and control the 
        complications resulting from, diabetes among Indian 
        T[t]ribes within that Service unit.
    (b) Diabetes Screening.--
    To the extent medically indicated and with informed 
consent, t[T]he Secretary shall screen each Indian who receives 
services from the Service for diabetes and for conditions which 
indicate a high risk that the individual will become diabetic 
and, in consultation with Indian Tribes, Urban Indian 
Organizations, and appropriate health care providers, establish 
a cost-effective approach to ensure ongoing monitoring of 
disease indicators. Such screening and monitoring may be 
conducted [done] by a Tribal Health Program and may be 
conducted through appropriate Internet-based health care 
management programs. [tribe or tribal organization operating 
health care programs or facilities with funds from the Service 
under the Indian Self-Determination Act [25 U.S.C.A. Sec. 450f 
et seq.].]
    (c) Funding for Diabetes.--The Secretary shall continue to 
fund each model diabetes project in existence on the date of 
the enactment of the Indian Health Care Improvement Amendments 
Act of 2004, any such other diabetes programs operated by the 
Service or Tribal Health Programs, and any additional diabetes 
projects, such as the Medical Vanguard program provided for in 
title IV of Public Law 108-87, as implemented to serve Indian 
Tribes. Tribal Health Programs shall receive recurring funding 
for the diabetes projects that they operate pursuant to this 
section, both at the date of enactment of the Indian Health 
Care Improvement Act Amendments of 2004 and for projects which 
are added and funded thereafter.
    [(c) Model diabetes projects
          [(1) The Secretary shall continue to maintain through 
        fiscal year 2000 each model diabetes project in 
        existence October 29, 1992 and located--
                  [(A) at the Claremore Indian Hospital in 
                Oklahoma;
                  [(B) at the Fort Totten Health Center in 
                North Dakota;
                  [(C) at the Sacaton Indian Hospital in 
                Arizona;
                  [(D) at the Winnebago Indian Hospital in 
                Nebraska;
                  [(E) at the Albuquerque Indian Hospital in 
                New Mexico;
                  [(F) at the Perry, Princeton, and Old Town 
                Health Centers in Maine;
                  [(G) at the Bellingham Health Center in 
                Washington;
                  [(H) at the Fort Berthold Reservation;
                  [(I) at the Navajo Reservation;
                  [(J) at the Papago Reservation;
                  [(K) at the Zuni Reservation; or
                  [(L) in the States of Alaska, California, 
                Minnesota, Montana, Oregon, or Utah.
          [(2) The Secretary may establish new model diabetes 
        projects under this section taking into consideration 
        applications received under this section from all 
        service areas, except that the Secretary may not 
        establish a greater number of such projects in one 
        service area than in any other service area until there 
        is an equal number of such projects established with 
        respect to all service areas from which the Secretary 
        receives qualified applications during the application 
        period (as determined by the Secretary).]
    (d) Funding for Dialysis Programs.--The Secretary shall 
provide funding through the Service, Indian Tribes, and Tribal 
Organizations to establish dialysis programs, including funding 
to purchase dialysis equipment and provide necessary staffing.
    [(d) Control officer; registry of patients
    [The Secretary shall--
          [(1) employ in each area office of the Service at 
        least one diabetes control officer who shall coordinate 
        and manage on a full-time basis activities within that 
        area office for the prevention, treatment, and control 
        of diabetes;
          [(2) establish in each area office of the Service a 
        registry of patients with diabetes to track the 
        incidence of diabetes and the complications from 
        diabetes in that area;
          [(3) ensure that data collected in each area office 
        regarding diabetes and related complications among 
        Indians is disseminated to all other area offices; and
          [(4) evaluate the effectiveness of services provided 
        through model diabetes projects established under this 
        section.]
    (e) Other Duties of the Secretary.--The Secretary shall, to 
the extent funding is available--
          (1) in each Area Office, consult with Indian Tribes 
        and Tribal Organizations regarding programs for the 
        prevention, treatment, and control of diabetes;
          (2) establish in each Area Office a registry of 
        patients with diabetes to track the incidence of 
        diabetes and the complications from diabetes in that 
        area; and
          (3) ensure that data collected in each Area Office 
        regarding diabetes and related complications among 
        Indians are disseminated to all other Area Offices, 
        subject to applicable patient privacy laws.
    [(e) Authorization of appropriations
    [Funds appropriated under this section in any fiscal year 
shall be in addition to base resources appropriated to the 
Service for that year.]

Sec. 205. Shared Services for Long-Term Care

    (a) Funding Agreements for Long-Term Care.--Notwithstanding 
any other provisions of law, the Secretary, acting through the 
Service, is authorized to enter into Funding Agreements or 
other arrangements with Indian Tribes or Tribal Organizations 
for the delivery of long-term care and similar services to 
Indians. Such funding agreements or other arrangements shall 
provide for the sharing of staff or other services between the 
Service or a Tribal Health Program and a long-term care or 
other similar facility owned and operated (directly or through 
a Funding Agreement) by such Indian Tribe or Tribal 
Organization.
    (b) Contents of Funding Agreements.--A Funding Agreement or 
other arrangement entered into pursuant to subsection (a)--
          (1) may, at the request of the Indian Tribe or Tribal 
        Organization, delegate to such Indian Tribe or Tribal 
        Organization such powers of supervision and control 
        over Service employees as the Secretary deems necessary 
        to carry out the purposes of this section;
          (2) shall provide that expenses (including salaries) 
        relating to services that are shared between the 
        Service and the Tribal Health Program be allocated 
        proportionately between the Service and the Indian 
        Tribe or Tribal Organization; and
          (3) may authorize such Indian Tribe or Tribal 
        Organization to construct, renovate, or expand a long-
        term care or other similar facility (including the 
        construction of a facility attached to a Service 
        facility).
    (c) Minimum Requirement.--Any nursing facility provided for 
under this section shall meet the requirements for nursing 
facilities under section 1919 of the Social Security Act.
    (d) Other Assistance.--The Secretary shall provide such 
technical and other assistance as may be necessary to enable 
applicants to comply with the provisions of this section.
    (e) Use of Existing or Underused Facilities.--The Secretary 
shall encourage the use of existing facilities that are 
underused or allow the use of swing beds for long-term or 
similar care.

[Sec. 1621d. Hospice care feasibility study

    [(a) Duty of Secretary
    [The Secretary, acting through the Service and in 
consultation with representatives of Indian tribes, tribal 
organizations, Indian Health Service personnel, and hospice 
providers, shall conduct a study--
          [(1) to assess the feasibility and desirability of 
        furnishing hospice care to terminally ill Indians; and
          [(2) to determine the most efficient and effective 
        means of furnishing such care.
    [(b) Functions of study
    [Such study shall--
          [(1) assess the impact of Indian culture and beliefs 
        concerning death and dying on the provision of hospice 
        care to Indians;
          [(2) estimate the number of Indians for whom hospice 
        care may be appropriate and determine the geographic 
        distribution of such individuals;
          [(3) determine the most appropriate means to 
        facilitate the participation of Indian tribes and 
        tribal organizations in providing hospice care;
          [(4) identify and evaluate various means for 
        providing hospice care, including--
                  [(A) the provision of such care by the 
                personnel of a Service hospital pursuant to a 
                hospice program established by the Secretary at 
                such hospital; and
                  [(B) the provision of such care by a 
                community-based hospice program under contract 
                to the Service; and
          [(5) identify and assess any difficulties in 
        furnishing such care and the actions needed to resolve 
        such difficulties.
    [(c) Report to Congress
    [Not later than the date which is 12 months after October 
29, 1992, the Secretary shall transmit to the Congress a report 
containing--
          [(1) a detailed description of the study conducted 
        pursuant to this section; and
          [(2) a discussion of the findings and conclusions of 
        such study.
    [(d) Definitions
    [For the purposes of this section--
          [(1) the term ``terminally ill'' means any Indian who 
        has a medical prognosis (as certified by a physician) 
        of a life expectancy of six months or less; and
          [(2) the term ``hospice program'' means any program 
        which satisfies the requirements of section 
        1395x(dd)(2) of Title 42; and
          [(3) the term ``hospice care'' means the items and 
        services specified in subparagraphs (A) through (H) of 
        section 1395x(dd)(1) of Title 42.]

Sec. 206. Health Services Research

    The Secretary, acting through the Service, shall make 
funding available for research to further the performance of 
the health service responsibilities of Indian Health Programs 
andshall coordinate the activities of other agencies within the 
Department to address these research needs. Tribal Health Programs 
shall be given an equal opportunity to compete for, and receive, 
research funds under this section. This funding may be used for both 
clinical and nonclinical research.

[Sec. 1621e. Reimbursement from certain third parties of costs of 
                    health services

    [(a) Right of recovery
    [Except as provided in subsection (f) of this section, the 
United States, an Indian tribe, or a tribal organization shall 
have the right to recover the reasonable expenses incurred by 
the Secretary, an Indian tribe, or a tribal organization in 
providing health services, through the Service, an Indian 
tribe, or tribal organization, to any individual to the same 
extent that such individual, or any nongovernmental provider of 
such services, would be eligible to receive reimbursement or 
indemnification for such expenses if--
          [(1) such services had been provided by a 
        nongovernmental provider, and
          [(2) such individual had been required to pay such 
        expenses and did pay such expenses.
    [(b) Recovery against State with workers' compensation laws 
or no-fault automobile accident insurance program
    [Subsection (a) of this section shall provide a right of 
recovery against any State only if the injury, illness, or 
disability for which health services were provided is covered 
under--
          [(1) workers' compensation laws, or
          [(2) a no-fault automobile accident insurance plan or 
        program.
    [(c) Prohibition of State law or contract provision 
impeding right of recovery
    [No law of any State, or of any political subdivision of a 
State, and no provision of any contract entered into or renewed 
after November 23, 1988, shall prevent or hinder the right of 
recovery of the United States, an Indian tribe, or a tribal 
organization under subsection (a) of this section.
    [(d) Right to damages
    [No action taken by the United States, an Indian tribe, or 
a tribal organization to enforce the right of recovery provided 
under subsection (a) of this section shall affect the right of 
any person to any damages (other than damages for the cost of 
health services provided by the Secretary through the Service).
    [(e) Intervention or separate civil action
    [The United States, an Indian tribe, or a tribal 
organization may enforce the right of recovery provided under 
subsection (a) of this section by--
          [(1) intervening or joining in any civil action or 
        proceeding brought--
                  [(A) by the individual for whom health 
                services were provided by the Secretary, an 
                Indian tribe, or a tribal organization, or
                  [(B) by any representative or heirs of such 
                individual, or
          [(2) instituting a separate civil action, after 
        providing to such individual, or to the representative 
        or heirs of such individual, notice of the intention of 
        the United States, an Indian tribe, or a tribal 
        organization to institute a separate civil action.
    [(f) Right of recovery for services when self-insurance 
plan provides coverage
    [The United States shall not have a right of recovery under 
this section if the injury, illness, or disability for which 
health services were provided is covered under a self-insurance 
plan funded by an Indian tribe or tribal organization.]

Sec. 207. Mammography and Other Cancer Screening

    The Secretary, acting through the Service or Tribal Health 
Programs, shall provide for screening as follows:
          (1) Screening mammography (as defined in section 
        1861(jj) of the Social Security Act) for Indian women 
        at a frequency appropriate to such women under national 
        standards, such as those of the National Cancer 
        Institute for the National Institutes for Health, and 
        under such terms and conditions as are consistent with 
        standards established by the Secretary to ensure the 
        safety and accuracy of screening mammography under part 
        B of title XVIII of such Act.
          (2) Other cancer screening meeting national 
        standards, such as those of the National Cancer 
        Institute.

[Sec. 1621f. Crediting of reimbursements

    [(a) Except as provided in section 1621a(d) of this title, 
subchapter III-A of this chapter, and section 1680c of this 
title, all reimbursements received or recovered, under 
authority of this chapter, Public Law 87-693 (42 U.S.C. 2651, 
et seq.), or any other provision of law, by reason of the 
provision of health services by the Service or by a tribe or 
tribal organization under a contract pursuant to the Indian 
Self-Determination Act [25 U.S.C.A. Sec. 450f et seq.] shall be 
retained by the Service or that tribe or tribal organization 
and shall be available for the facilities, and to carry out the 
programs, of the Service or that tribe or tribal organization 
to provide health care services to Indians.
    [(b) The Service may not offset or limit the amount of 
funds obligated to any service unit or any entity under 
contract with the Service because of the receipt of 
reimbursements under subsection (a) of this section.]

Sec. 208. Patient Travel Costs

    The Secretary, acting through the Service and Tribal Health 
Programs, shall provide funds for the following patient travel 
costs, including appropriate and necessary qualified escorts, 
associated with receiving health care services provided (either 
through direct or contract care or through Funding Agreements) 
under this Act--
          (1) emergency air transportation and non-emergency 
        air transportation where ground transportation is 
        infeasible;
          (2) transportation by private vehicle (where no other 
        means of transportation is available), specially 
        equipped vehicle, and ambulance; and
          (3) transportation by such other means as may be 
        available and required when air or motor vehicle 
        transportation is not available.

[Sec. 1621g. Health services research

    [Of the amounts appropriated for the Service in any fiscal 
year, other than amounts made available for the Indian Health 
Care Improvement Fund, not less than $200,000 shall be 
available only for research to further the performance of the 
health service responsibilities of the Service. Indian tribes 
and tribal organizations contracting with the Service under the 
authority of the Indian Self-Determination Act [25 U.S.C.A. 
Sec. 450f et seq.] shall be given an equal opportunity to 
compete for, and receive, research funds under this section.]

Sec. 209. Epidemiology Centers

    (a) Additional Centers.--In addition to those epidemiology 
centers already established at the time of enactment of this 
Act, (including those for which funding is currently being 
provided in Funding Agreements), and without reducing the 
funding levels for such centers, not later than 180 days after 
the date of the enactment of the Indian Health Care Improvement 
Act Amendments of 2004, the Secretary, acting through the 
Service, shall establish and fund an epidemiology center in 
each Service Area which does not yet have one to carry out the 
functions described in subsection (b). Any new centers so 
established may be operated by Tribal Health Programs, but such 
funding shall not be divisible.
    (b) Functions of Centers.--In consultation with and upon 
the request of Indian Tribes, Tribal Organizations, and Urban 
Indian Organizations, each Service Area epidemiology center 
established under this subsection shall, with respect to such 
Service Area--
          (1) collect data relating to, and monitor progress 
        made toward meeting, each of the health status 
        objectives of the Service, the Indian Tribes, Tribal 
        Organizations, and Urban Indian Organizations in the 
        Service Area;
          (2) evaluate existing delivery systems, data systems, 
        and other systems that impact the improvement of Indian 
        health;
          (3) assist Indian Tribes, Tribal Organizations, and 
        Urban Indian Organizations in identifying their highest 
        priority health status objectives and the services 
        needed to achieve such objectives, based on 
        epidemiological data;
          (4) make recommendations for the targeting of 
        services needed by the populations served;
          (5) make recommendations to improve health care 
        delivery systems for Indians and Urban Indians;
          (6) provide requested technical assistance to Indian 
        Tribes, Tribal Organizations, and Urban Indian 
        Organizations in the development of local health 
        service priorities and incidence and prevalence rates 
        of disease and other illness in the community; and
          (7) provide disease surveillance and assist Indian 
        Tribes, Tribal Organizations, and Urban Indian 
        Organizations to promote public health.
    (c) Technical Assistance.--The Director of the Centers for 
Disease Control and Prevention shall provide technical 
assistance to the centers in carrying out the requirements of 
this subsection.
    (d) Funding for Studies.--The Secretary may make funding 
available to Indian Tribes, Tribal Organizations, and Urban 
Indian Organizations to conduct epidemiological studies of 
Indian communities.

[Sec. 1621h. Mental health prevention and treatment services

    [(a) National plan for Indian Mental Health Services
          [(1) Not later than 120 days after November 28, 1990, 
        the Secretary, acting through the Service, shall 
        develop and publish in the Federal Register a final 
        national plan for Indian Mental Health Services. The 
        plan shall include--
                  [(A) an assessment of the scope of the 
                problem of mental illness and dysfunctional and 
                self-destructive behavior, including child 
                abuse and family violence, among Indians, 
                including--
                          [(i) the number of Indians served by 
                        the Service who are directly or 
                        indirectly affected by such illness or 
                        behavior, and
                          [(ii) an estimate of the financial 
                        and human cost attributable to such 
                        illness or behavior;
                  [(B) an assessment of the existing and 
                additional resources necessary for the 
                prevention and treatment of such illness and 
                behavior; and
                  [(C) an estimate of the additional funding 
                needed by the Service to meet its 
                responsibilities under the plan.
          [(2) The Secretary shall submit a copy of the 
        national plan to the Congress.
    [(b) Memorandum of agreement
    [Not later than 180 days after November 28, 1990, the 
Secretary and the Secretary of the Interior shall develop and 
enter into a memorandum of agreement under which the 
Secretaries shall, among other things--
          [(1) determine and define the scope and nature of 
        mental illness and dysfunctional and self-destructive 
        behavior, including child abuse and family violence, 
        among Indians;
          [(2) make an assessment of the existing Federal, 
        tribal, State, local, and private services, resources, 
        and programs available to provide mental health 
        services for Indians;
          [(3) make an initial determination of the unmet need 
        for additional services, resources, and programs 
        necessary to meet the needs identified pursuant to 
        paragraph (1);
          [(4)(A) ensure that Indians, as citizens of the 
        United States and of the States in which they reside, 
        have access to mental health services to which all 
        citizens have access;
          [(B) determine the right of Indians to participate 
        in, and receive the benefit of, such services; and
          [(C) take actions necessary to protect the exercise 
        of such right;
          [(5) delineate the responsibilities of the Bureau of 
        Indian Affairs and the Service, including mental health 
        identification, prevention, education, referral, and 
        treatment services (including services through 
        multidisciplinary resource teams), at the central, 
        area, and agency and service unit levels to address the 
        problems identified in paragraph (1);
          [(6) provide a strategy for the comprehensive 
        coordination of the mental health services provided by 
        the Bureau of Indian Affairs and the Service to meet 
        the needs identified pursuant to paragraph (1), 
        including--
                  [(A) the coordination of alcohol and 
                substance abuse programs of the Service, the 
                Bureau of Indian Affairs, and the various 
                tribes (developed under the Indian Alcohol and 
                Substance Abuse Prevention and Treatment Act of 
                1986) [25 U.S.C.A. Sec. 2401 et seq.] with the 
                mental health initiatives pursuant to this 
                chapter, particularly with respect to the 
                referral and treatment of dually-diagnosed 
                individuals requiring mental health and 
                substance abuse treatment; and
                  [(B) ensuring that Bureau of Indian Affairs 
                and Service programs and services (including 
                multidisciplinary resource teams) addressing 
                child abuse and family violence are coordinated 
                with such non-Federal programs and services;
          [(7) direct appropriate officials of the Bureau of 
        Indian Affairs and the Service, particularly at the 
        agency and service unit levels, to cooperate fully with 
        tribal requests made pursuant to subsection (d) of this 
        section; and
          [(8) provide for an annual review of such agreement 
        by the two Secretaries.
    [(c) Community mental health plan
          [(1) The governing body of any Indian tribe may, at 
        its discretion, adopt a resolution for the 
        establishment of a community mental health plan 
        providing for the identification and coordination of 
        available resources and programs to identify, prevent, 
        or treat mental illness or dysfunctional and self-
        destructive behavior, including child abuse and family 
        violence, among its members.
          [(2) In furtherance of a plan established pursuant to 
        paragraph (1) and at the request of a tribe, the 
        appropriate agency, service unit, or other officials of 
        the Bureau of Indian Affairs and the Service shall 
        cooperate with, and provide technical assistance to, 
        the tribe in the development of such plan. Upon the 
        establishment of such a plan and at the request of the 
        tribe, such officials, as directed by the memorandum of 
        agreement developed pursuant to subsection (c), of this 
        section, shall cooperate with the tribe in the 
        implementation of such plan.
          [(3) Two or more Indian tribes may form a coalition 
        for the adoption of resolutions and the establishment 
        and development of a joint community mental health plan 
        under this subsection.
          [(4) The Secretary, acting through the Service, may 
        make grants to Indian tribes adopting a resolution 
        pursuant to paragraph (1) to obtain technical 
        assistance for the development of a community mental 
        health plan and to provide administrative support in 
        the implementation of such plan.
    [(d) Mental health training and community education 
programs
          [(1) The Secretary and the Secretary of the Interior, 
        in consultation with representatives of Indian tribes, 
        shall conduct a study and compile a list, of the types 
        of staff positions specified in paragraph (2) whose 
        qualifications include, or should include, training in 
        the identification, prevention, education, referral, or 
        treatment of mental illness or dysfunctional and self-
        destructive behavior.
          [(2) The positions referred to in paragraph (1) are--
                  [(A) staff positions within the Bureau of 
                Indian Affairs, including existing positions, 
                in the fields of--
                          [(i) elementary and secondary 
                        education;
                          [(ii) social services and family and 
                        child welfare;
                          [(iii) law enforcement and judicial 
                        services; and
                          [(iv) alcohol and substance abuse;
                  [(B) staff positions with the Service; and
                  [(C) staff positions similar to those 
                identified in subparagraphs (A) and (B) 
                established and maintained by Indian tribes, 
                including positions established in contracts 
                entered into under the Indian Self-
                Determination Act [25 U.S.C.A. Sec. 450f et 
                seq.].
          [(3)(A) The appropriate Secretary shall provide 
        training criteria appropriate to each type of position 
        identified in paragraph (2)(A) and ensure that 
        appropriate training has been, or will be, provided to 
        any individual in any such position. With respect to 
        any such individual in a position identified pursuant 
        to paragraph (2)(C), the respective Secretaries shall 
        provide appropriate training to, or provide funds to an 
        Indian tribe for the training of, such individual. In 
        the case of positions funded under a contract entered 
        into under the Indian Self-Determination Act [25 
        U.S.C.A. Sec. 450f et seq.], the appropriate Secretary 
        shall ensure that such training costs are included in 
        the contract, if necessary.
          [(B) Funds authorized to be appropriated pursuant to 
        this section may be used to provide training authorized 
        by this paragraph for community education programs 
        described in paragraph (5) if a plan adopted pursuant 
        to subsection (d) of this section identifies 
        individuals or employment categories, other than those 
        identified pursuant to paragraph (1), for which such 
        training or community education is deemed necessary or 
        desirable.
          [(4) Position-specific training criteria described in 
        paragraph (3) shall be culturally relevant to Indians 
        and Indian tribes and shall ensure that appropriate 
        information regarding traditional Indian healing and 
        treatment practices is provided.
          [(5) The Service shall develop and implement or, upon 
        the request of an Indian tribe, assist such tribe to 
        develop andimplement, a program of community education 
on mental illness and dysfunctional and self-destructive behavior for 
individuals, as determined in a plan adopted pursuant to subsection (d) 
of this section. In carrying out this paragraph, the Service shall 
provide, upon the request of an Indian tribe, technical assistance to 
the Indian tribe to obtain or develop community education and training 
materials on the identification, prevention, referral, and treatment of 
mental illness and dysfunctional and self-destructive behavior.
    [(e) Staffing
          [(1) Within 90 days after November 28, 1990, the 
        Secretary shall develop a plan under which the Service 
        will increase the health care staff providing mental 
        health services by at least 500 positions within five 
        years after November 28, 1990, with at least 200 of 
        such positions devoted to child, adolescent, and family 
        services. Such additional staff shall be primarily 
        assigned to the service unit level for services which 
        shall include outpatient, emergency, aftercare and 
        follow-up, and prevention and education services.
          [(2) The plan developed under paragraph (1) shall be 
        implemented under section 13 of this title.
    [(f) Staff recruitment and retention
          [(1) The Secretary shall provide for the recruitment 
        of the additional personnel required by subsection (f) 
        of this section and the retention of all Service 
        personnel providing mental health services. In carrying 
        out this subsection, the Secretary shall give priority 
        to practitioners providing mental health services to 
        children and adolescents with mental health problems.
          [(2) In carrying out paragraph (1), the Secretary 
        shall develop a program providing for--
                  [(A) the payment of bonuses (which shall not 
                be more favorable than those provided for under 
                section 1616i and 1616j of this title) for 
                service in hardship posts;
                  [(B) the repayment of loans (for which the 
                provisions of repayment contracts shall not be 
                more favorable than the repayment contracts 
                under section 1616a of this title) for health 
                professions education as a recruitment 
                incentive; and
                  [(C) a system of postgraduate rotations as a 
                retention incentive.
          [(3) This subsection shall be carried out in 
        coordination with the recruitment and retention 
        programs under subchapter I of this chapter.
    [(g) Mental Health Technician program
          [(1) Under the authority of section 13 of this title, 
        the Secretary shall establish and maintain a Mental 
        Health Technician program within the Service which--
                  [(A) provides for the training of Indians as 
                mental health technicians; and
                  [(B) employs such technicians in the 
                provision of community-based mental health care 
                that includes identification, prevention, 
                education, referral, and treatment services.
          [(2) In carrying out paragraph (1)(A), the Secretary 
        shall provide high standard paraprofessional training 
        in mental health care necessary to provide quality care 
        to the Indian communities to be served. Such training 
        shall be based upon a curriculum developed or approved 
        by the Secretary which combines education in the theory 
        of mental health care with supervised practical 
        experience in the provision of such care.
          [(3) The Secretary shall supervise and evaluate the 
        mental health technicians in the training program.
          [(4) The Secretary shall ensure that the program 
        established pursuant to this subsection involves the 
        utilization and promotion of the traditional Indian 
        health care and treatment practices of the Indian 
        tribes to be served.
    [(h) Mental health research
    [The Secretary, acting through the Service and in 
consultation with the National Institute of Mental Health, 
shall enter into contracts with, or make grants to, appropriate 
institutions for the conduct of research on the incidence and 
prevalence of mental disorders among Indians on Indian 
reservations and in urban areas. Research priorities under this 
subsection shall include--
          [(1) the inter-relationship and inter-dependence of 
        mental disorders with alcoholism, suicide, homicides, 
        accidents, and the incidence of family violence, and
          [(2) the development of models of prevention 
        techniques.
[The effect of the inter-relationships and 
interdependenciesreferred to in paragraph (1) on children, and the 
development of prevention techniques under paragraph (2) applicable to 
children, shall be emphasized.
    [(i) Facilities assessment
    [Within one year after November 28, 1990, the Secretary, 
acting through the Service, shall make an assessment of the 
need for inpatient mental health care among Indians and the 
availability and cost of inpatient mental health facilities 
which can meet such need. In making such assessment, the 
Secretary shall consider the possible conversion of existing, 
under-utilized service hospital beds into psychiatric units to 
meet such need.
    [(j) Annual report
    [The Service shall develop methods for analyzing and 
evaluating the overall status of mental health programs and 
services for Indians and shall submit to the President, for 
inclusion in each report required to be transmitted to the 
Congress under section 1671 of this title, a report on the 
mental health status of Indians which shall describe the 
progress being made to address mental health problems of Indian 
communities.
    [(k) Mental health demonstration grant program
          [(1) The Secretary, acting through the Service, is 
        authorized to make grants to Indian tribes and inter-
        tribal consortia to pay 75 percent of the cost of 
        planning, developing, and implementing programs to 
        deliver innovative community-based mental health 
        services to Indians. The 25 percent tribal share of 
        such cost may be provided in cash or through the 
        provision of property or services.
          [(2) The Secretary may award a grant for a project 
        under paragraph (1) to an Indian tribe or inter-tribal 
        consortium which meets the following criteria:
                  [(A) The project will address significant 
                unmet mental health needs among Indians.
                  [(B) The project will serve a significant 
                number of Indians.
                  [(C) The project has the potential to deliver 
                services in an efficient and effective manner.
                  [(D) The tribe or consortium has the 
                administrative and financial capability to 
                administer the project.
                  [(E) The project will deliver services in a 
                manner consistent with traditional Indian 
                healing and treatment practices.
                  [(F) The project is coordinated with, and 
                avoids duplication of, existing services.
          [(3) For purposes of this subsection, the Secretary 
        shall, in evaluating applications for grants for 
        projects to be operated under any contract entered into 
        with the Service under the Indian Self-Determination 
        Act [25 U.S.C.A. Sec. 450f et seq.], use the same 
        criteria that the Secretary uses in evaluating any 
        other application for such a grant.
          [(4) The Secretary may only award one grant under 
        this subsection with respect to a service area until 
        the Secretary has awarded grants for all service areas 
        with respect to which the Secretary receives 
        applications during the application period, as 
        determined by the Secretary, which meet the criteria 
        specified in paragraph (2).
          [(5) Not later than 180 days after the close of the 
        term of the last grant awarded pursuant to this 
        subsection, the Secretary shall submit to the Congress 
        a report evaluating the effectiveness of the innovative 
        community-based projects demonstrated pursuant to this 
        subsection. Such report shall include findings and 
        recommendations, if any, relating to the reorganization 
        of the programs of the Service for delivery of mental 
        services to Indians.
          [(6) Grants made pursuant to this section may be 
        expended over a period of three years and no grant may 
        exceed $1,000,000 for the fiscal years involved.
    [(l) Licensing requirement for mental health care workers
    [Any person employed as a psychologist, social worker, or 
marriage and family therapist for the purpose of providing 
mental health care services to Indians in a clinical setting 
under the authority of this chapter or through a contract 
pursuant to the Indian Self-Determination Act [25 U.S.C.A. 
Sec. 450f et. seq.] shall--
          [(1) in the case of a person employed as a 
        psychologist, be licensed as a clinical psychologist or 
        working under the direct supervision of a licensed 
        clinical psychologist;
          [(2) in the case of a person employed as a social 
        worker,be licensed as a social worker or working under 
the direct supervision of a licensed social worker; or
          [(3) in the case of a person employed as a marriage 
        and family therapist, be licensed as a marriage and 
        family therapist or working under the direct 
        supervision of a licensed marriage and family 
        therapist.
    [(m) Intermediate adolescent mental health services
          [(1) The Secretary, acting through the Service, may 
        make grants to Indian tribes and tribal organizations 
        to provide intermediate mental health services to 
        Indian children and adolescents, including--
                  [(A) inpatient and outpatient services;
                  [(B) emergency care;
                  [(C) suicide prevention and crisis 
                intervention; and
                  [(D) prevention and treatment of mental 
                illness, and dysfunctional and self-destructive 
                behavior, including child abuse and family 
                violence.
          [(2) Funds provided under this subsection may be 
        used--
                  [(A) to construct or renovate an existing 
                health facility to provide intermediate mental 
                health services;
                  [(B) to hire mental health professionals;
                  [(C) to staff, operate, and maintain an 
                intermediate mental health facility, group 
                home, or youth shelter where intermediate 
                mental health services are being provided; and
                  [(D) to make renovations and hire appropriate 
                staff to convert existing hospital beds into 
                adolescent psychiatric units.
          [(3) Funds provided under this subsection may not be 
        used for the purposes described in section 1621o(b)(1) 
        of this title.
          [(4) An Indian tribe or tribal organization receiving 
        a grant under this subsection shall ensure that 
        intermediate adolescent mental health services are 
        coordinated with other tribal, Service, and Bureau of 
        Indian Affairs mental health, alcohol and substance 
        abuse, and social services programs on the reservation 
        of such tribe or tribal organization.
          [(5) The Secretary shall establish criteria for the 
        review and approval of applications for grants made 
        pursuant to this subsection.
          [(6) There are authorized to be appropriated to carry 
        out this section $10,000,000 for fiscal year 1993 and 
        such sums as may be necessary for each of the fiscal 
        year 1993 and such sums as may be necessary for each of 
        the fiscal years 1994, 1995, 1996, 1997, 1998, 1999, 
        and 2000.]

Sec. 210. Comprehensive Health Education Programs

    (a) Funding for Development of Programs.--The Secretary, 
acting through the Service, shall provide funding to Indian 
Tribes, Tribal Organizations, and Urban Indian Organizations to 
develop comprehensive school health education programs for 
children from pre-school through grade 12 in schools for the 
benefit of Indian and Urban Indian children.
    (b) Use of Funds.--Funding provided under this section may 
be used for purposes which may include, but are not limited to, 
the following:
          (1) Developing and implementing health education 
        curricula both for regular school programs and 
        afterschool programs.
          (2) Training teachers in comprehensive school health 
        education curricula.
          (3) Integrating school-based, community-based, and 
        other public and private health promotion efforts.
          (4) Encouraging healthy, tobacco-free school 
        environments.
          (5) Coordinating school-based health programs with 
        existing services and programs available in the 
        community.
          (6) Developing school programs on nutrition 
        education, personal health, oral health, and fitness.
          (7) Developing behavioral health wellness programs.
          (8) Developing chronic disease prevention programs.
          (9) Developing substance abuse prevention programs.
          (10) Developing injury prevention and safety 
        education programs.
          (11) Developing activities for the prevention and 
        control or communicable diseases.
          (12) Developing community and environmental health 
        education programs that include traditional health care 
        practitioners.
          (13) Violence prevention.
          (14) Such other health issues as are appropriate.
    (c) Technical Assistance.--Upon request, the Secretary, 
acting through the Service, shall provide technical assistance 
to Indian Tribes, Tribal Organizations, and Urban Indian 
Organizations in the development of comprehensive health 
education plans and the dissemination of comprehensive health 
education materials and information on existing health programs 
and resources.
    (d) Criteria for Review and Approval of Applications.--The 
Secretary, acting through the Service, and in consultation with 
Indian Tribes, Tribal Organizations, and Urban Indian 
Organizations, shall establish criteria for the review and 
approval of applications for funding provided pursuant to this 
section.
    (e) Development of Program for BIA Funded Schools.--
          (1) In general.--The Secretary of the Interior, 
        acting through the Bureau of Indian Affairs and in 
        cooperation with the Secretary, acting through the 
        Service, and affected Indian Tribes and Tribal 
        Organizations, shall develop a comprehensive school 
        health education program for children from preschool 
        through grade 12 in schools for which support is 
        provided by the Bureau of Indian Affairs.
          (2) Requirements for programs.--Such programs shall 
        include--
                  (A) school programs on nutrition education, 
                personal health, oral health, and fitness;
                  (B) behavioral health wellness programs;
                  (C) chronic disease prevention programs;
                  (D) substance abuse prevention programs;
                  (E) injury prevention and safety education 
                programs; and
                  (F) activities for the prevention and control 
                of communicable diseases.
          (3) Duties of the secretary.--The Secretary of the 
        Interior shall--
                  (A) provide training to teachers in 
                comprehensive school health education 
                curricula;
                  (B) ensure the integration and coordination 
                of school-based programs with existing services 
                and health programs available in the community; 
                and
                  (C) encourage healthy, tobacco-free school 
                environments.

[Sec. 1621i. Managed care feasibility study

    [(a) The Secretary, acting through the Service, shall 
conduct a study to assess the feasibility of allowing an Indian 
tribe to purchase, directly or through the Service, managed 
care coverage for all members of the tribe from--
          [(1) a tribally owned and operated managed care plan; 
        or
          [(2) a State licensed managed care plan.
    [(b) Not later than the date which is 12 months after 
October 29, 1992, the Secretary shall transmit to the Congress 
a report containing--
          [(1) a detailed description of the study conducted 
        pursuant to this section; and
          [(2) a discussion of the findings and conclusions of 
        such study.]

Sec. 211. Indian Youth Program

    (a) Program Authorized.--The Secretary, acting through the 
Service, is authorized to establish and administer a program to 
provide funding to Indian Tribes, Tribal Organizations, and 
Urban Indian Organizations for innovative mental and physical 
disease prevention and health promotion and treatment programs 
for Indian and Urban Indian preadolescent and adolescent 
youths.
    (b) Use of Funds.--
          (1) Allowable uses.--Funds made available under this 
        section may be used to--
                  (A) develop prevention and treatment programs 
                for Indian youth which promote mental and 
                physical health and incorporate cultural 
                values, community and family involvement, and 
                traditional health care practitioners; and
                  (B) develop and provide community training 
                and education.
          (2) Prohibited use.--Funds made available under this 
        section may not be used to provide services described 
        in section 707(c).
    (c) Duties of the Secretary.--The Secretary shall--
          (1) disseminate to Indian Tribes, Tribal 
        Organizations, and Urban Indian Organizations 
        information regarding models for the delivery of 
        comprehensive health care services to Indian and Urban 
        Indian adolescents;
          (2) encourage the implementation of such models; and
          (3) at the request of an Indian Tribe, Tribal 
        Organization, or Urban Indian Organization, provide 
        technical assistance in the implementation of such 
        models.
    (d) Criteria for Review and Approval of Applications.--The 
Secretary, in consultation with Indian Tribes, Tribal 
Organizations, and Urban Indian Organizations, shall establish 
criteria for the review and approval of applications or 
proposals under this section.

[Sec. 1621j. California contract health services demonstration program

    [(a) Establishment
    [The Secretary shall establish a demonstration program to 
evaluate the use of a contract care intermediary to improve the 
accessibility of health services to California Indians.
    [(b) Agreement with California Rural Indian Health Board
          [(1) In establishing such program, the Secretary 
        shall enter into an agreement with the California Rural 
        Indian Health Board to reimburse the Board for costs 
        (including reasonable administrative costs) incurred, 
        during the period of the demonstration program, in 
        providing medical treatment under contract to 
        California Indians described in section 1679(b) of this 
        title throughout the California contract health 
        services delivery area described in section 1680 of 
        this title with respect to high-cost contract care 
        cases.
          [(2) Not more than 5 percent of the amounts provided 
        to the Board under this section for any fiscal year may 
        be for reimbursement for administrative expenses 
        incurred by the Board during such fiscal year.
          [(3) No payment may be made for treatment provided 
        under the demonstration program to the extent payment 
        may be made for such treatment under the Catastrophic 
        Health Emergency Fund described in section 1621a of 
        this title or from amounts appropriated or otherwise 
        made available to the California contract health 
        service delivery area for a fiscal year.
    [(c) Advisory board
    [There is hereby established an advisory board which shall 
advise the California Rural Indian Health Board in carrying out 
the demonstration pursuant to this section. The advisory board 
shall be composed of representatives, selected by the 
California Rural Indian Health Board, from not less than 8 
tribal health programs serving California Indians covered under 
such demonstration, at least one half of whom are not 
affiliated with the California Rural Indian Health Board.
    [(d) Commencement and termination dates
    [The demonstration program described in this section shall 
begin on January 1, 1993, and shall terminate on September 30, 
1997.
    [(e) Report
    [Not later than July 1, 1998, the California Rural Indian 
Health Board shall submit to the Secretary a report on the 
demonstration program carried out under this section, including 
a statement of its findings regarding the impact of using a 
contract care intermediary on--
          [(1) access to needed health services;
          [(2) waiting periods for receiving such services; and
          [(3) the efficient management of high-cost contract 
        care cases.
    [(f) ``High-cost contract care cases'' defined
    [For the purposes of this section, the term ``high-cost 
contract care cases'' means those cases in which the cost of 
the medical treatment provided to an individual--
          [(1) would otherwise be eligible for reimbursement 
        from the Catastrophic Health Emergency Fund established 
        under section 1621a of this title, except that the cost 
        of such treatment does not meet the threshold cost 
        requirement established pursuant to section 1621a(b)(2) 
        of this title; and
          [(2) exceeds $1,000.
    [(g) Authorization of appropriations
    [There are authorized to be appropriated for each of the 
fiscal years 1996 through 2000 such sums as may be necessary to 
carry out the purposes of this section.]

Sec. 212. Prevention, Control, and Elimination of Communicable and 
                    Infectious Diseases

    (a) Funding Authorized.--The Secretary, acting through the 
Service, and after consultation with Indian Tribes, Tribal 
Organizations, Urban Indian Organizations, and the Centers for 
Disease Control and Prevention, may make funding available to 
Indian Tribes, Tribal Organizations, and Urban Indian 
Organizations for the following:
          (1) Projects for the prevention, control, and 
        elimination of communicable and infectious diseases 
        including, but not limited to, tuberculosis, hepatitis, 
        human immunodeficiency virus, respiratory syncytial 
        virus, hanta virus, sexually transmitted diseases, and 
        Helicobacter Pylori Infections.
          (2) Public information and education programs for the 
        prevention, control, and elimination of communicable 
        and infectious diseases.
          (3) Education, training, and clinical skills 
        improvement activities in the prevention, control, and 
        elimination of communicable and infectious diseases for 
        health professionals, including allied health 
        professionals.
          (4) Demonstration projects for the screening, 
        treatment, and prevention of hepatitis C virus (HCV).
    (b) Application Required.--The Secretary may provide 
funding under subsection (a) only if an application or proposal 
for funding is submitted to the Secretary.
    (c) Coordination With Health Agencies.--Indian Tribes, 
Tribal Organizations, and Urban Indian Organizations receiving 
funding under this section are encouraged to coordinate their 
activities with the Centers for Disease Control and Prevention 
and State and local health agencies.
    (d) Technical Assistance; Report.--In carrying out this 
section, the Secretary--
          (1) may, at the request of an Indian Tribe, Tribal 
        Organization, or Urban Indian Organization, provide 
        technical assistance; and
          (2) shall prepare and submit a report to Congress 
        biennially on the use of funds under this section and 
        on the progress made toward the prevention, control, 
        and elimination of communicable and infectious diseases 
        among Indians and Urban Indians.

[Sec. 1621k. Coverage of screening mammography

    [The Secretary, through the Service, shall provide for 
screening mammography (as defined in section 1861(jj) of the 
Social Security Act [42 U.S.C.A. Sec. 1395x9JJ0]) for Indian 
and urban Indian women 35 years of age or older at a frequency, 
determined by the Secretary (in consultation with the Director 
of the National Cancer Institute), appropriate to such women, 
and under such terms and conditions as are consistent with 
standards established by the Secretary to assure the safety and 
accuracy of screening mammography under part B of title XVIII 
of the Social Security Act [42 U.S.C.A. Sec. 1395j et. seq.]. ]

Sec. 213. Authority for Provision of Other Services

    (a) Funding Authorized.--The Secretary, acting through the 
Service, Indian Tribes, and Tribal Organizations, may provide 
funding under this Act to meet the objectives set forth in 
section 3 through health care-related services and programs not 
otherwise described in this Act, which shall include, but not 
be limited to--
          (1) hospice care;
          (2) assisted living;
          (3) long-term health care;
          (4) home- and community-based services;
          (5) public health functions; and
          (6) Traditional Health Care Practices.
    (b) Services to Otherwise Ineligible Persons.--At the 
discretion of the Service, Indian Tribes, or Tribal 
Organizations, services provided for hospice care, home health 
care, home- and community-based care, assisted living, and 
long-term care may be provided (subject to reimbursement of 
reasonable charges) to persons otherwise ineligible for the 
health care benefits of the Service. Any funds received under 
this subsection shall not be used to offset or limit the 
funding allocated to an Indian Tribe or Tribal Organization.
    (c) Definitions.--For the purposes of this section, the 
following definitions shall apply:
          (1) The term `home- and community-based services' 
        means 1 or more of the following:
                  (A) Homemaker/home health aide services.
                  (B) Chore services.
                  (C) Personal care services.
                  (D) Nursing care services provided outside of 
                a nursing facility by, or under the supervision 
                of, a registered nurse.
                  (E) Respite care.
                  (F) Training for family members.
                  (G) Adult day care.
                  (H) Such other home- and community-based 
                services as the Secretary, an Indian Tribe, or 
                Tribal Organization may approve.
          (2) The term `hospice care' means the items and 
        services specified in subparagraphs (A) through (H) of 
        section 1861(dd)(1) of the Social Security Act (42 
        U.S.C. 1395x(dd)(1)), and such other services which an 
        Indian Tribe or Tribal Organization determines are 
        necessary and appropriate to provide in furtherance of 
        this care.
          (3) The term `public health functions' means the 
        provision of public health-related programs, functions, 
        and services including, but not limited to, assessment, 
        assurance, and policy development which Indian Tribes 
        and Tribal Organizations are authorized and encouraged, 
        in those circumstances where it meets their needs, to 
        do by forming collaborative relationships with all 
        levels of local, State, and Federal Government.

[Sec. 1621l. Patient travel costs

    [(a) The Secretary, acting through the Service, shall 
provide funds for the following patient travel costs associated 
with receiving health care services provided (either through 
direct or contract care or through contracts entered into 
pursuant to the Indian Self-Determination Act [25 U.S.C.A. 
Sec. 450f et. seq.]) under this chapter--
          [(1) emergency air transportation; and
          [(2) nonemergency air transportation where ground 
        transportation is infeasible.
      [(b) There are authorized to be appropriated to carry out 
this section $15,000,000 for fiscal year 1993 and such sums as 
may be necessary for each of the fiscal years 1994, 1995, 1996, 
1997, 1998, 1999, and 2000.]

Sec. 214. Indian Women's Health Care

    The Secretary, acting through the Service and Indian 
Tribes, Tribal Organizations, and Urban Indian Organizations, 
shall provide funding to monitor and improve the quality of 
health care for Indian women of all ages through the planning 
and delivery of programs administered by the Service, in order 
to improve and enhance the treatment models of care for Indian 
women.

[Sec. 1621m. Epidemiology centers

    [(a)(1) The Secretary shall establish an epidemiology 
center in each Service area to carry out the functions 
described in paragraph (3).
    [(2) To assist such centers in carrying out such functions, 
the Secretary shall perform the following:
          [(A) In consultation with the Centers for Disease 
        Control and Indian tribes, develop sets of data (which 
        to the extent practicable, shall be consistent with the 
        uniform datasets used by the States with respect to the 
year 2000 health objectives) for uniformly defining health status for 
purposes of the objectives specified in section 1602(b) of this title. 
Such sets shall consist of one or more categories of information. The 
Secretary shall develop formats for the uniform collecting and 
reporting of information on such categories.
          [(B) Establish and maintain a system for monitoring 
        the progress made toward meeting each of the health 
        status objectives described in section 1602(b) of this 
        title.
    [(3) In consultation with Indian tribes and urban Indian 
communities, each area epidemiology center established under 
this subsection shall, with respect to such area--
          [(A) collect data relating to, and monitor progress 
        made toward meeting, each of the health status 
        objectives described in section 1602(b) of this title 
        using the data sets and monitoring system developed by 
        the Secretary pursuant to paragraph (2);
          [(B) evaluate existing delivery systems, data 
        systems, and other systems that impact the improvement 
        of Indian health;
          [(C) assist tribes and urban Indian communities in 
        identifying their highest priority health status 
        objectives and the services needed to achieve such 
        objectives, based on epidemiological data;
          [(D) make recommendations for the targeting of 
        services needed by tribal, urban, and other Indian 
        communities;
          [(E) make recommendations to improve health care 
        delivery systems for Indians and urban Indians;
          [(F) work cooperatively with tribal providers of 
        health and social services in order to avoid 
        duplication of existing services; and
          [(G) provide technical assistance to Indian tribes 
        and urban Indian organizations in the development of 
        local health service priorities and incidence and 
        prevalence rates of disease and other illness in the 
        community.
      [(4) Epidemiology centers established under this 
subsection shall be subject to the provisions of the Indian 
Self-Determination Act (25 U.S.C. 450f et seq.).
      [(5) The director of the Centers for Disease Control 
shall provide technical assistance to the centers in carrying 
out the requirements of this subsection.
      [(6) The Service shall assign one epidemiologist from 
each of its area offices to each area epidemiology center to 
provide such center with technical assistance necessary to 
carry out this subsection.
      [(b)(1) The Secretary may make grants to Indian tribes, 
tribal organizations, and eligible intertribal consortia or 
Indian organization to conduct epidemiological studies of 
Indian communities.
      [(2) An intertribal consortia or Indian organization is 
eligible to receive a grant under this subsection if--
          [(A) it is incorporated for the primary purpose of 
        improving Indian health; and
          [(B) it is representative of the tribes or urban 
        Indian communities in which it is located.
      [(3) An application for a grant under this subsection 
shall be submitted in such manner and at such time as the 
Secretary shall prescribe.
      [(4) Applicants for grants under this subsection shall--
          [(A) demonstrate the technical, administrative, and 
        financial expertise necessary to carry out the 
        functions described in paragraph (5);
          [(B) consult and cooperate with providers of related 
        health and social services in order to avoid 
        duplication of existing services; and
          [(C) demonstrate cooperation from Indian tribes or 
        urban Indian organizations in the area to be served.
      [(5) A grant awarded under paragraph (1) may be used to--
          [(A) carry out the functions described in subsection 
        (a)(3) of this section;
          [(B) provide information to and consult with tribal 
        leaders, urban Indian community leaders, and related 
        health staff, on health care and health services 
        management issues; and
          [(C) provide, in collaboration with tribes and urban 
        Indian communities, the Service with information 
        regarding waysto improve the health status of Indian 
people.
      [(6) There are authorized to be appropriated to carry out 
the purposes of this subsection not more that $12,000,000 for 
fiscal year 1993 and such sums as may be necessary for each of 
the fiscal years 1994, 1995, 1996, 1997, 1998, 1999, and 2000.]

Sec. 215. Environmental and Nuclear Health Hazards

    (a) Studies and Monitoring.--The Secretary and the Service 
shall conduct, in conjunction with other appropriate Federal 
agencies and in consultation with concerned Indian Tribes and 
Tribal Organizations, studies and ongoing monitoring programs 
to determine trends in the health hazards to Indian miners and 
to Indians on or near reservations and Indian communities as a 
result of environmental hazards which may result in chronic or 
life threatening health problems, such as nuclear resource 
development, petroleum contamination, and contamination of 
water source and of the food chain. Such studies shall 
include--
          (1) an evaluation of the nature and extent of health 
        problems caused by environmental hazards currently 
        exhibited among Indians and the causes of such health 
        problems;
          (2) an analysis of the potential effect of ongoing 
        and future environmental resource development on or 
        near reservations and Indian communities, including the 
        cumulative effect over time on health;
          (3) and evaluation of the types and nature of 
        activities, practices, and conditions causing or 
        affecting such health problems including, but not 
        limited to, uranium mining and milling, uranium mining 
        tailing deposits, nuclear power plant operation and 
        construction, and nuclear waste disposal; oil and gas 
        production or transportation on or near reservations or 
        Indian communities; and other development that could 
        affect the health of Indians and their water supply and 
        food chain;
          (4) a summary of any findings and recommendations 
        provided in Federal and State studies, reports, 
        investigations, and inspections during the 5 years 
        prior to the date of the enactment of the Indian Health 
        Care Improvement Act Amendments of 2004 that directly 
        or indirectly relate to the activities, practices, and 
        conditions affecting the health or safety of such 
        Indians; and
          (5) the efforts that have been made by Federal and 
        State agencies and resource and economic development 
        companies to effectively carry out an education program 
        for such Indians regarding the health and safety 
        hazards of such development.
    (b) Health Care Plans.--Upon completion of such studies, 
the Secretary and the Service shall take into account the 
results of such studies and, in consultation with Indian Tribes 
and Tribal Organizations, develop health care plans to address 
the health problems studied under subsection (a). The plans 
shall include--
          (1) methods for diagnosing and treating Indians 
        currently exhibiting such health problems;
          (2) preventive care and testing for Indians who may 
        be exposed to such health hazards, including the 
        monitoring of the health of individuals who have or may 
        have been exposed to excessive amounts of radiation or 
        affected by other activities that have had or could 
        have a serious impact upon the health of such 
        individuals; and
          (3) a program of education for Indians who, by reason 
        of their work or geographic proximity to such nuclear 
        or other development activities, may experience health 
        problems.
    (c) Submission of Report and Plan to Congress.--The 
Secretary and the Service shall submit to Congress the study 
prepared under subsection (a) no later than 18 months after the 
date of the enactment of the Indian Health Care Improvement Act 
Amendments of 2004. The health care plan prepared under 
subsection (b) shall be submitted in a report no later than 1 
year after the study prepared under subsection (a) is submitted 
to Congress. Such report shall include recommended activities 
for the implementation of the plan, as well as an evaluation of 
any activities previously undertaken by the Service to address 
such health problems.
    (d) Intergovernmental Task Force.--
          (1) Establishment; members.--There is established an 
        Intergovernmental Task Force to be composed of the 
        following individuals (or their designees):
                  (A) The Secretary of Energy.
                  (B) The Secretary of the Environmental 
                Protection Agency.
                  (C) The Director of the Bureau of Mines.
                  (D) The Assistant Secretary for Occupational 
                Safetyand Health.
                  (E) The Secretary of the Interior.
                  (F) The Secretary of Health and Human 
                Services.
                  (G) The Director of the Indian Health 
                Service.
          (2) Duties.--The Task Force shall--
                  (A) identify existing and potential 
                operations related to nuclear resource 
                development or other environmental hazards that 
                affect or may affect the health of Indians on 
                or near a reservation or in an Indian 
                community; and
                  (B) enter into activities to correct existing 
                health hazards and ensure that current and 
                future health problems resulting from nuclear 
                resource or other development activities are 
                minimized or reduced.
          (3) Chairman; meetings.--The Secretary of Health and 
        Human Services shall be the Chairman of the Task Force. 
        The Task Force shall meet at least twice each year.
    (e) Health Services to Certain Employees.--In the case of 
any Indian who--
          (1) as a result of employment in or near a uranium 
        mine or mill or near any other environmental hazard, 
        suffers from a work-related illness or condition;
          (2) is eligible to receive diagnosis and treatment 
        services from an Indian Health Program; and
          (3) by reason of such Indian's employment, is 
        entitled to medical care at the expense of such mine or 
        mill operator or entity responsible for the 
        environmental hazard, the Indian Health Program shall, 
        at the request of such Indian, render appropriate 
        medical care to such Indian for such illness or 
        condition and may be reimbursed for any medical care so 
        rendered to which such Indian is entitled at the 
        expense of such operator or entity from such operator 
        or entity. Nothing in this subsection shall affect the 
        rights of such Indian to recover damages other than 
        such amounts paid to the Indian Health Program from the 
        employer for providing medical care for such illness or 
        condition.

[Sec. 1621n. Comprehensive school health education programs

    [(a) Award of grants
    [The Secretary, acting through the Service and in 
consultation with the Secretary of the Interior, may award 
grants to Indian tribes to develop comprehensive school health 
education programs for children from preschool through grade 12 
in schools located on Indian reservations.
    [(b) Use of grants
    [Grants awarded under this section may be used to--
          [(1) develop health education curricula;
          [(2) train teachers in comprehensive school health 
        education curricula;
          [(3) integrate school-based, community-based, and 
        other public and private health promotion efforts;
          [(4) encourage healthy, tobacco-free school 
        environments;
          [(5) coordinate school-based health programs with 
        existing services and programs available in the 
        community;
          [(6) develop school programs on nutrition education, 
        personal health, and fitness;
          [(7) develop mental health wellness programs;
          [(8) develop chronic disease prevention programs;
          [(9) develop substance abuse prevention programs;
          [(10) develop accident prevention and safety 
        education programs;
          [(11) develop activities for the prevention and 
        control of communicable diseases; and
          [(12) develop community and environmental health 
        education programs.
    [(c) Assistance
    [The Secretary shall provide technical assistance to Indian 
tribes in the development of health education plans, and the 
dissemination of health education materials and information on 
existing health programs and resources.
    [(d) Criteria for review and approval of applications
    [The Secretary shall establish criteria for the review and 
approval of applications for grants made pursuant to this 
section.
    [(e) Report of recipient
    [Recipients of grants under this section shall submit to 
the Secretary an annual report on activities undertaken with 
funds provided under this section. Such reports shall include a 
statement of--
          [(1) the number of preschools, elementary schools, 
        and secondary schools served;
          [(2) the number of students served;
          [(3) any new curricula established with funds 
        provided under this section;
          [(4) the number of teachers trained in the health 
        curricula; and
          [(5) the involvement of parents, members of the 
        community, and community health workers in programs 
        established with funds provided under this section.
    [(f) Program development
          [(1) The Secretary of the Interior, acting through 
        the Bureau of Indian Affairs and in cooperation with 
        the Secretary, shall develop a comprehensive school 
        health education program for children from preschool 
        through grade 12 in schools operated by the Bureau of 
        Indian Affairs.
          [(2) Such program shall include--
                  [(A) school programs on nutrition education, 
                personal health, and fitness;
                  [(B) mental health wellness programs;
                  [(C) chronic disease prevention programs;
                  [(D) substance abuse prevention programs;
                  [(E) accident prevention and safety education 
                programs; and
                  [(F) activities for the prevention and 
                control of communicable diseases.
          [(3) The Secretary of the Interior shall--
                  [(A) provide training to teachers in 
                comprehensive school health education 
                curricula;
                  [(B) ensure the integration and coordination 
                of school-based programs with existing services 
                and health programs available in the community; 
                and
                  [(C) encourage healthy, tobacco-free school 
                environments.
    [(g) Authorization of appropriations
    [There are authorized to be appropriated to carry out this 
section $15,000,000 for the fiscal year 1993 and such sums as 
may be necessary for each of the fiscal years 1994, 1995, 1996, 
1997, 1998, 1999, and 2000.]

Sec. 216. Arizona as a Contract Health Service Delivery Area

    (a) In General.--For fiscal years beginning with the fiscal 
year ending September 30, 1983, and ending with the fiscal year 
ending September 30, 2015, the State of Arizona shall be 
designated as a contract health service delivery area by the 
Service for the purpose of providing contract health care 
services to members of federally recognized Indian Tribes of 
Arizona.
    (b) Maintenance of Services.--The Service shall not curtail 
any health care services provided to Indians residing on 
reservations in the State of Arizona if such curtailment is due 
to the provision of contract services in such State pursuant to 
the designation of such State as a contract health service 
delivery area pursuant to subsection (a).

Sec. 216A. North Dakota as a Contract Health Service Delivery Area

    (a) In General.--For fiscal years beginning with the fiscal 
year ending September 30, 2003, and ending with the fiscal year 
ending September 30, 2015, the State of North Dakota shall be 
designated as a contract health service delivery area by the 
Service for the purpose of providing contract health care 
services to members of federally recognized Indian Tribes of 
North Dakota.
    (b) Limitation.--The Service shall not curtail any health 
care services provided to Indians residing on reservations in 
theState of North Dakota if such curtailment is due to the 
provision of contract services in such State pursuant to the 
designation of such State as a contract health service delivery area 
pursuant to subsection (a).

Sec. 216B. South Dakota as a Contract Health Service Delivery Area

    (a) In General.--For fiscal years beginning with the fiscal 
year ending September 30, 2003, and ending with the fiscal year 
ending on September 30, 2015, the State of South Dakota shall 
be designated as a contract health service delivery area by the 
Service for the purpose of providing contract health care 
services to members of federally recognized Indian Tribes of 
South Dakota.
    (b) Limitation.--The Service shall not curtail any health 
care services provided to Indians residing on reservations in 
the State of South Dakota if such curtailment is due to the 
provision of contract services in such State pursuant to the 
designation of such State as a contract health service delivery 
area pursuant to subsection (a).

[Sec. 1621o. Indian youth grant program

    [(a) Grants
    [The Secretary, acting through the Service, is authorized 
to make grants to Indian tribes, tribal organizations, and 
urban Indian organizations for innovative mental and physical 
disease prevention and health promotion and treatment programs 
for Indian preadolescent and adolescent youths.
    [(b) Use of funds
          [(1) Funds made available under this section may be 
        used to--
                  [(A) develop prevention and treatment 
                programs for Indian youth which promote mental 
                and physical health and incorporate cultural 
                values, community and family involvement, and 
                traditional healers; and
                  [(B) develop and provide community training 
                and education.
          [(2) Funds made available under this section may not 
        be used to provide services described in section 
        1621h(m) of this title.
    [(c) Models for delivery of comprehensive health care 
services
    [The Secretary shall--
          [(1) disseminate to Indian tribes information 
        regarding models for the delivery of comprehensive 
        health care services to Indian and urban Indian 
        adolescents;]
          [(2) encourage the implementation of such models; 
        and]
          [(3) at the request of an Indian tribe, provide 
        technical assistance in the implementation of such 
        models.
    [(d) Criteria for review and approval of applications
    [The Secretary shall establish criteria for the review and 
approval of applications under this section.
    [(e) Authorization of appropriations
    [There are authorized to be appropriated to carry out this 
section $5,000,000 for fiscal yar 1993 and such sums as may be 
necessary for each of the fiscal years 1994, 1995, 1996, 1997, 
1998, 1999, and 2000.]

Sec. 217. California Contract Health Services Program

    (a) Funding Authorized.--The Secretary is authorized to 
fund a program using the California Rural Indian Health Board 
(hereafter in this section referred to as the 'CRIHB') as a 
contract care intermediary to improve the accessibility of 
health services to California Indians.
    (b) Reimbursement Contract.--The Secretary shall enter into 
an agreement with the CRIHB to reimburse the CRIHB for costs 
(including reasonable administrative costs) incurred pursuant 
to this section, in providing medical treatment under contract 
to California Indians described in section 806(a) throughout 
the California contract health services delivery area described 
in section 218 with respect to high cost contract care cases.
    (c) Administrative Expenses.--Not more than 5 percent of 
the amounts provided to the CRIHB under this section for any 
fiscal year may be for reimbursement for administrative 
expenses incurred by the CRIHB during such fiscal year.
    (d) Limitation on Payment.--No payment may be made for 
treatment provided hereunder to the extent payment may be made 
for such treatment under the Indian Catastrophic Health 
Emergency Funddescribed in section 202 or from amounts 
appropriated or otherwise made available to the California contract 
health service delivery area for a fiscal year.
    (e) Advisory Board.--There is hereby established an 
advisory board which shall advise the CRIHB in carrying out 
this section. The advisory board shall be composed of 
representatives, selected by the CRIHB, from not less than 8 
Tribal Health Programs serving California Indians covered under 
this section at least one half of whom are not affiliated with 
the CRIHB.

Sec. 218. California as a Contract Health Service Delivery Area

    The State of California, excluding the counties of Alameda, 
Contra Costa, Los Angeles, Marin, Orange, Sacramento, San 
Francisco, San Mateo, Santa Clara, Kern, Merced, Monterey, 
Napa, San Benito, San Joaquin, San Luis Obispo, Santa Cruz, 
Solano, Stanislaus, and Ventura, shall be designated as a 
contract health service delivery area by the Service for the 
purpose of providing contract health services to California 
Indians. However, any of the counties listed herein may only be 
included in the contract health services delivery area if 
funding is specifically provided by the Service for such 
services in those counties.

Sec. 219. Contract Health Services for the Trenton Service Area

    (a) Authorization for Services.--The Secretary, acting 
through the Service, is directed to provide contract health 
services to members of the Turtle Mountain Band of Chippewa 
Indians that reside in the Trenton Service Area of Divide, 
McKenzie, and Williams counties in the State of North Dakota 
and the adjoining counties of Richland, Roosevelt, and Sheridan 
in the State of Montana.
    (b) No Expansion of Eligibility.--Nothing in this section 
may be construed as expanding the eligibility of members of the 
Turtle Mountain Band of Chippewa Indians for health services 
provided by the Service beyond the scope of eligibility for 
such health services that applied on May 1, 1986.

[Sec. 1621p. American Indians Into Psychology Program

    [(a) Grants
    [The Secretary may provide grants to at least 3 colleges 
and universities for the purpose of developing and maintaining 
American Indian psychology career recruitment programs as a 
means of encouraging Indians to enter the mental health field.
    [(b) Quentin N. Burdick American Indians Into Psychology 
Program
    [The Secretary shall provide one of the grants authorized 
under subsection (a) of this section to develop and maintain a 
program at the University of North Dakota to be known as the 
``Quentin N. Burdick American Indians Into Psychology 
Program''. Such program shall, to the maximum extent feasible, 
coordinate with the Quentin N. Burdick Indian Health Programs 
authorized under section 1616g(b) of this title, the Quentin N. 
Burdick American Indians Indians Into Nursing Program 
authorized under section 1616e(e) of this title, and existing 
university research and communications networks.
    [(c) Issuance of regulations
          [(1) The Secretary shall issue regulations for the 
        competitive awarding of the grants provided under this 
        section.
          [(2) Applicants for grants under this section shall 
        agree to provide a program which, at a minimum--
                  [(A) provides outreach and recruitment for 
                health professions to Indian communities 
                including elementary, secondary and community 
                colleges located on Indian reservations that 
                will be served by the program;
                  [(B) incorporates a program advisory board 
                comprised of representatives from the tribes 
                and communities that will be served by the 
                program;
                  [(C) provides summer enrichment programs to 
                expose Indian students to the varied fields of 
                psychology through research, clinical, and 
                experiential activities;
                  [(D) provides stipends to undergraduate and 
                graduate students to pursue a career in 
                psychology;
                  [(E) develops affiliation agreements with 
                tribal community colleges, the Service, 
                university affiliated programs, and other 
                appropriate entities to enhance the education 
                of Indian students;
                  [(F) to the maximum extent feasible, utilizes 
                existing university tutoring, counseling and 
                student support services; and
                  [(G) to the maximum extent feasible, employs 
                qualified Indians in the program.
    [(d) Active duty service obligation
    [The active duty service obligation prescribed under 
section 254m of Title 42 shall be met by each graduate student 
who receives a stipend described in subsection (c)(2)(D) of 
this section that is funded by a grant provided under this 
section. Such obligation shall be met by service--
          [(1) in the Indian Health Service;
          [(2) in a program conducted under a contract entered 
        into under the Indian Self-Determination Act [25 
        U.S.C.A. Sec. 450f et seq.],
          [(3) in a program assisted under subchapter IV of 
        this chapter; or
          [(4) in the private practice of psychology if, as 
        determined by the Secretary, in accordance with 
        guidelines promulgated by the Secretary, such practice 
        is situated in a physician or other health professional 
        shortage area and addresses the health care needs of a 
        substantial number of Indians.

[Sec. 1621q. Prevention, control, and elimination of tuberculosis

    [(a) Grants
    [The Secretary, acting through the Service after 
consultation with the Centers for Disease Control, may make 
grants to Indian tribes and tribal organizations for--
          [(1) projects for the prevention, control, and 
        elimination of tuberculosis;
          [(2) public information and education programs for 
        the prevention, control, and elimination of 
        tuberculosis; and
          [(3) education, training, and clinical skills 
        improvement activities in the prevention, control, and 
        elimination of tuberculosis for health professionals, 
        including allied health professionals.
    [(b) Application for grant
    [The Secretary may make a grant under subsection (a) of 
this section only if an application for the grant is submitted 
to the Secretary and the application is in such form, is made 
in such manner, and contains the assurances required by 
subsection (c) of this section and such other agreements, 
assurances, and information as the Secretary may require.
    [(c) Eligibility for grant
    [To be eligible for a grant under subsection (a) of this 
section, an applicant must provide assurances satisfactory to 
the Secretary that--
          [(1) the applicant will coordinate its activities for 
        the prevention, control, and elimination of 
        tuberculosis with activities of the Centers for Disease 
        Control, and State and local health agencies; and
          [(2) the applicant will submit to the Secretary an 
        annual report on its activities for the prevention, 
        control, and elimination of tuberculosis.
    [(d) Duties of Secretary
    [In carrying out this section, the Secretary--
          [(1) shall establish criteria for the review and 
        approval of applications for grants under subsection 
        (a) of this section, including requirement of public 
        health qualifications of applicants;
          [(2) shall, subject to available appropriations, make 
        at least one grant under subsection (a) of this section 
        within each area office;
          [(3) may, at the request of an Indian tribe or tribal 
        organization, provide technical assistance; and
          [(4) shall prepare and submit a report to the 
        Committee on Energy and Commerce and the Committee on 
        Natural Resources of the House and the Committee on 
        Indian Affairs of the Senate not later than February 1, 
        1994, and biennially thereafter, on the use of funds 
        under this section and on the progress made toward the 
        prevention, control, and elimination of tuberculosis 
        among Indian tribes and tribal organizations.
    [(e) Reduction of amount of grant
    [The Secretary may, at the request of a recipient of a 
grant under subsection (a) of this section, reduce the amount 
of such grant by--
          [(1) the fair market value of any supplies or 
        equipment furnished the grant recipient; and
          [(2) the amount of the pay, allowances, and travel 
        expenses of any officer or employee of the Government 
        when detailed to the grant recipient and the amount of 
        any other costs incurred in connection with the detail 
        of such officer or employee,
when the furnishing of such supplies or equipment or the detail 
of such an officer or employee is for the convenience of and at 
the request of such grant recipient and for the purpose of 
carrying out a program with respect to which the grant under 
subsection (a) of this section is made. The amount by which any 
such grant is so reduced shall be available for payment by the 
Secretary of the costs incurred in furnishing the supplies or 
equipment, or in detailing the personnel, on which the 
reduction of such grant is based, and such amount shall be 
deemed as part of the grant and shall be deemed to have been 
paid to the grant recipient.

[Sec. 1621r. Contract health services payment study

    [(a) Duty of Secretary
    [The Secretary, acting through the Service and in 
consultation with representatives of Indian tribes and tribal 
organizations operating contract health care programs under the 
Indian Self-Determination Act (25 U.S.C. 450f et seq.) or under 
self-governance compacts, Service personnel, private contract 
health services providers, the Indian Health Service Fiscal 
Intermediary, and other appropriate experts, shall conduct a 
study--
          [(1) to assess and identify administrative barriers 
        that hinder the timely payment for services delivered 
        by private contract health services providers to 
        individual Indians by the Service and the Indian Health 
        Service Fiscal Intermediary;
          [(2) to assess and identify the impact of such 
        delayed payments upon the personal credit histories of 
        individual Indians who have been treated by such 
        providers; and
          [(3) to determine the most efficient and effective 
        means of improving the Service's contract health 
        services payment system and ensuring the development of 
        appropriate consumer protection policies to protect 
        individual Indians who receive authorized services from 
        private contract health services providers from billing 
        and collection practices, including the development of 
        materials and programs explaining patients' rights and 
        responsibilities.
    [(b) Functions of study
    [The study required by subsection (a) of this section 
shall--
          [(1) assess the impact of the existing contract 
        health services regulations and policies upon the 
        ability of the Service and the Indian Health Service 
        Fiscal Intermediary to process, on a timely and 
        efficient basis, the payment of bills submitted by 
        private contract health services providers;
          [(2) assess the financial and any other burdens 
        imposed upon individual Indians and private contract 
        health services providers by delayed payments;
          [(3) survey the policies and practices of collection 
        agencies used by contract health services providers to 
        collect payments for services rendered to individual 
        Indians;
          [(4) identify appropriate changes in Federal 
        policies, administrative procedures, and regulations, 
        to eliminate the problems experienced by private 
        contract health services providers and individual 
        Indians as a result of delayed payments; and
          [(5) compare the Service's payment processing 
        requirements with private insurance claims processing 
        requirement to evaluate the systemic differences or 
        similarities employed by the Service and private 
        insurers.
    [(c) Report to congress
    [Not later than 12 months after October 29, 1992, the 
Secretary shall transmit to the Congress a report that 
includes--
          [(1) a detailed description of the study conducted 
        pursuant to this section; and
          [(2) a discussion of the findings and conclusions of 
        such study.

[Sec. 1621s. Prompt action on payment of claims

    [(a) Time of response
    [The Service shall respond to a notification of a claim by 
a provider of a contract care service with either an individual 
purchase order or a denial of the claim within 5 working days 
after the receipt of such notification.
    [(b) Failure to timely respond
    [If the Service fails to respond to a notification of a 
claim in accordance with subsection (a) of this section, the 
Service shall accept as valid the claim submitted by the 
provider of a contract care service.
    [(c) Time of payment
    [The Service shall pay a completed contract care service 
claim within 30 days after completion of the claim.

[Sec. 1621t. Demonstration of electronic claims processing

    [(a) Not later than June 15, 1993, the Secretary shall 
develop and implement, directly or by contract, 2 projects to 
demonstrate in a pilot setting the use of claims processing 
technology to improve the accuracy and timeliness of the 
billing for, and payment of, contract health services.
    [(b) The Secretary shall conduct one of the projects 
authorized in subsection (a) of this section in the Service 
area served by the area office located in Phoenix, Arizona.

[Sec. 1621u. Liability for payment

    [(a) A patient who receives contract health care services 
that are authorized by the Service shall not be liable for the 
payment of any charges or costs associated with the provision 
of such services.
    [(b) The Secretary shall notify a contract care provider 
and any patient who receives contract health care services 
authorized by the Service that such patient is not liable for 
the payment of any charges or costs associated with the 
provision of such services.

[Sec. 1621v. Office of Indian Women's Health Care

    [There is established within the Service an Office of 
Indian Women's Health Care to oversee efforts of the Service to 
monitor and improve the quality of health care for Indian women 
of all ages through the planning and delivery of programs 
administered by the Service, in order to improve and enhance 
the treatment models of care for Indian women.]

Sec. 220. Programs Operated by Indian Tribes and Tribal Organizations

    The Service shall provide funds for health care programs 
and facilities operated by Tribal Health Programs on the same 
basis as such funds are provided to programs and facilities 
operated directly by the Service.

Sec. 221. Licensing or Certification

    Health care professionals employed by a Tribal Health 
Program shall, if licensed or certified in any State, be exempt 
from the licensing or certification requirements of the State 
in which the Tribal Health Program performs the services 
described in its Funding Agreement.

Sec. 222. Notification of Provision of Emergency Contract Health 
                    Services

    With respect to an elderly Indian or an Indian with a 
disability receiving emergency medical care or services from a 
non-Service provider or in a non-Service facility under the 
authority of this Act, the time limitation (as a condition of 
payment) for notifying the Service of such treatment or 
admission shall be 30 days.

Sec. 223. Prompt Action on Payment of Claims

    (a) Deadline for Response.--The Service shall respond to a 
notification of a claim by a provider of a contract care 
service with either an individual purchase order or a denial of 
the claim within 5 working days after the receipt of such 
notification.
    (b) Effect of Untimely Response.--If the Service fails to 
respond to a notification of a claim in accordance with 
subsection (a), the Service shall accept as valid the claim 
submitted by the provider of a contract care service.
    (c) Deadline for Payment of Valid Claim--The Service shall 
pay a valid contract care service claim within 30 days after 
the completion of the claim.

Sec. 224. Liability for Payment

    (a) No Patient Liability.--A patient who receives contract 
health care services that are authorized by the Service shall 
not be liable for the payment of any charges or costs 
associated with the provision of such services.
    (b) Notification.--The Secretary shall notify a contract 
care provider and any patient who receives contract health care 
services authorized by the Service that such patient is 
notliable for the payment of any charges or costs associated with the 
provision of such services not later than 5 business days after receipt 
of a notification of a claim by a provider of contract care services.
    (c) No Recourse.--Following receipt of the notice provided 
under subsection (b), or, if a claim has been deemed accepted 
under section 233(b), the provider shall have no further 
recourse against the patient who received the services.

Sec. 1621w. Authorization of appropriations

    [Except as provided in sections 1621h(m), 1621j, 1621l, 
1621m(b)(5), 1621n, and 1621o of this title, t] There are 
authorized to be appropriated such sums as may be necessary for 
each fiscal year through fiscal year 2015 [2000] to carry out 
this title [subchapter].

[Sec. 1621x. Limitation on use of funds

    [Amounts appropriated to carry out this subchapter may not 
be used in a manner inconsistent with the Assisted Suicide 
Funding Restriction Act of 1997 [42 U.S.C.A. Sec. 14401 et 
seq.].

[Sec. 1622. Transferred]

              TITLE [SUBCHAPTER] III--[HEALTH] FACILITIES

Sec. 1631. Consultation: Construction and Renovation of Facilities; 
                    [closure of facilities; r]Reports

    (a) Prerequisites for Expenditure of Funds.--[Consultation; 
standards for accreditation]
    Prior to the expenditure of, or the making of any binding 
[firm] commitment to expend, any funds appropriated for the 
planning, design, construction, or renovation of facilities 
pursuant to the Act of November 2, 1921 (25 U.S.C. 13) 
(commonly known as the `Snyder Act') [section 13 of this title, 
popularly known as the Snyder Act], the Secretary, acting 
through the Service, shall--
          (1) consult with any Indian [t]Tribe that would be 
        significantly affected by such expenditure for the 
        purpose of determining and, whenever practicable, 
        honoring tribal preferences concerning size, location, 
        type, and other characteristics of any facility on 
        which such expenditure is to be made[,]; and
          (2) ensure, whenever practicable and applicable, that 
        such facility meets the construction standards of any 
        accrediting body recognized by the Secretary for the 
        purposes of the medicare, medicaid, and SCHIP programs 
        under titles XVIII, XIX, and XXI of the Social Security 
        Act [the Joint Commission on Accreditation of Health 
        Care Organizations] by not later than 1 year after the 
        date on which the construction or renovation of such 
        facility is completed.
    (b) Closures.--[; report on proposed closure]
          (1) Evaluation required.--Notwithstanding any other 
        provision of law, no facility operated by the Service 
        [other than this subsection, no Service hospital or 
        outpatient health care facility of the Service, or any 
        portion of such a hospital or facility,] may be closed 
        if the Secretary has not submitted to [the] Congress at 
        least 1 year prior to the date of the proposed closure 
        [such hospital or facility (or portion thereof) is 
        proposed to be closed] an evaluation of the impact of 
        the [such] proposed closure which specifies, in 
        addition to other considerations--
                  (A) the accessibility of alternative health 
                care resources for the population served by 
                such [hospital or] facility;
                  (B) the cost-effectiveness of such closure;
                  (C) the quality of health care to be provided 
                to the population served by such [hospital or] 
                facility after such closure;
                  (D) the availability of contract health care 
                funds to maintain existing levels of service;
                  (E) the views of the Indian [t]Tribes served 
                by such [hospital or] facility concerning such 
                closure;
                  (F) the level of use of such [utilization of 
                such hospital or] facility by all eligible 
                Indians; and
                  (G) the distance between such [hospital or] 
                facility and the nearest operating Service 
                hospital.
          (2) Exception for certain temporary closures.--
        Paragraph (1) shall not apply to any temporary closure 
        of a facility or [of] any portion of a facility if such 
        closure is necessary for medical, environmental, or 
        construction safety reasons.
    (c) Health Care Facility Priority System.--[Annual report 
on health facility priority system]
          (1) In general.--
                  (A) Establishment.--The Secretary, acting 
                through the Service, shall establish a health 
                care facility priority system, which shall--
                          (i) be developed with Indian Tribes 
                        and Tribal Organizations through 
                        negotiated rulemaking under section 
                        802;
                          (ii) give Indian Tribes' needs the 
                        highest priority; and
                          (iii) at a minimum, include the lists 
                        required in paragraph (2)(B) and the 
                        methodology required in paragraph 
                        (2)(E).
                  (B) Priority of certain projects protected.--
                The priority of any project established under 
                the construction priority system in effect on 
                the date of the Indian Health Care Improvement 
                Act Amendments of 2004 shall not be affected by 
                any change in the construction priority system 
                taking place thereafter if the project was 
                identified as 1 of the 10 top-priority 
                inpatient projects, 1 of the 10 top-priority 
                outpatient projects, 1 of the 10 top-priority 
                staff quarters developments, or 1 of the 10 
                top-priority Youth Regional Treatment Centers 
                in the fiscal year 2005 Indian Health Service 
                budget justification, or if the project had 
                completed both Phase I and Phase II of the 
                construction priority system in effect on the 
                date of the enactment of such Act.
          (2)[(1)] Report; contents.--The Secretary shall 
        submit to the President, for inclusion in each report 
        required to be transmitted to [the] Congress under 
        section 801 [1671 of this title], a report which sets 
        forth the following:[--]
                  (A) A description of the [current] health 
                care facility priority system of the Service, 
                established under paragraph (1).
                  (B) Health care facilities lists, including 
                but not limited to--[the planning, design, 
                construction, and renovation needs for the 10 
                top-priority inpatient care facilities and the 
                10 top-priority ambulatory care facilities 
                (together with required staff quarters),]
                          (i) the 10 top-priority inpatient 
                        health care facilities;
                          (ii) the 10 top-priority outpatient 
                        health care facilities;
                          (iii) the 10 top-priority specialized 
                        health care facilities (such as long-
                        term care and alcohol and drug abuse 
                        treatment);
                          (iv) the 10 top-priority staff 
                        quarters developments associated with 
                        health care facilities; and
                          (v) the 10 top-priority patient 
                        hostels associated with health care 
                        facilities.
                  (C) [t]The justification for such order of 
                priority[,].
                  (D) [t]The projected cost of such projects.[, 
                and]
                  (E) [t]The methodology adopted by the Service 
                in establishing priorities under its health 
                facility priority system.
          (3)[(2)] Requirements for preparation of reports.--In 
        preparing each report required under paragraph (2)[(1)] 
        (other than the initial report), the Secretary shall 
        annually--
                  (A) consult with and obtain information on 
                all health care facilities needs from Indian 
                [t]Tribes, Tribal Organizations, and Urban 
                Indian Organizations; [and tribal organizations 
                including those tribes or tribal organizations 
                operating health programs or facilities under 
                any contract entered into with the Service 
                under the Indian Self-Determination Act [25 
                U.S.C.A. Sec. 450f et seq.],] and
                  (B) review the total unmet needs of all 
                Indian [such t] Tribes, Tribal Organizations, 
                and Urban Indian Organizations [and tribal 
                organizations] for health care [inpatient and 
                outpatient] facilities (including hostels and 
                staff quarters), including [their] needs for 
                renovation and expansion of existing 
                facilities.
          (4)[(3)] Criteria for evaluating needs.--For purposes 
        of this subsection, the Secretary shall, in evaluating 
        the needs of facilities operated under any Funding 
        Agreement [contract entered into with the Service under 
        the Indian Self-Determination Act [25 U.S.C.A. 
        Sec. 450f et seq.],] use the same criteria that the 
        Secretary uses in evaluating the needs of facilities 
        operated directly by the Service.
         (5)[(4)] Needs of facilities under isdeaa 
        agreements.--TheSecretary shall ensure that the 
planning, design, construction, and renovation needs of Service and 
non-Service facilities operated under funding agreements in accordance 
with the [which are the subject of a contract for health services 
entered into with the Service under the] Indian Self-Determination and 
Education Assistance Act (25 U.S.C. 450 et seq.) [[25 U.S.C.A. 
Sec. 450f et seq.]] are fully and equitably integrated into [the 
development of] the health care facility priority system.
    (d) Review of Need for Facilities
          (1) Initial report.--In the year 2005, the Government 
        Accountability Office shall prepare and finalize a 
        report which sets forth the needs of the Service, 
        Indian Tribes, Tribal Organizations, and Urban Indian 
        Organizations, for the facilities listed under 
        subsection (c)(2)(B), including the needs for 
        renovation and expansion of existing facilities. The 
        Government Accountability Office shall submit the 
        report to the appropriate authorizing and 
        appropriations committees of Congress and to the 
        Secretary.
          (2) Beginning in the year 2006, the Secretary shall 
        update the report required under paragraph (1) every 5 
        years.
          (3) The Comptroller General and the Secretary shall 
        consult with Indian Tribes, Tribal Organizations, and 
        Urban Indian Organizations. The Secretary shall submit 
        the reports required by paragraphs (1) and (2), to the 
        President for inclusion in the report required to be 
        transmitted to Congress under section 801.
          (4) For purposes of this subsection, the reports 
        shall, regarding the needs of facilities operated under 
        any Funding Agreement, be based on the same criteria 
        that the Secretary uses in evaluating the needs of 
        facilities operated directly by the Service.
          (5) The planning, design, construction, and 
        renovation needs of facilities operated under Funding 
        Agreements shall be fully and equitably integrated into 
        the development of the health facility priority system.
          (6) Beginning in the year 2006 and each fiscal year 
        thereafter, the Secretary shall provide an opportunity 
        for nomination of planning, design, and construction 
        projects by the Service, Indian Tribes, and Tribal 
        Organizations for consideration under the health care 
        facility priority system.
    (e) Funding Condition.--[(d) Funds appropriated subject to 
section 450f of this title]
    All funds appropriated under the Act of November 2, 1921 
(25 U.S.C. 13) (commonly known as the `Snyder Act'), [section 
13 of this title,] for the planning, design, construction, or 
renovation of health facilities for the benefit of 1 or more 
[an] Indian [tribe or t]Tribes shall be subject to the 
provisions of [section 102 of] the Indian Self-Determination 
and Education Assistance Act (25 U.S.C. 450 et seq.) [[25 
U.S.C.A. Sec. 450f]].
    (f) Development of Innovative Approaches.-- The Secretary 
shall consult and cooperate with Indian Tribes, Tribal 
Organizations, and Urban Indian Organizations in developing 
innovative approaches to address all or part of the total unmet 
need for construction of health facilities, including those 
provided for in other sections of this title and other 
approaches.

Sec. 1632. Sanitation [Safe water and sanitary waster disposal 
                    f]Facilities

    (a) [Congressional f]Findings.--
    [The] Congress [hereby] finds the following: [and declares 
that--]
          (1) [t]The provision of sanitation facilities [safe 
        water supply systems and sanitary sewage and solid 
        waste disposal systems] is primarily a health 
        consideration and function[;].
          (2) Indian people suffer an inordinately high 
        incidence of disease, injury, and illness directly 
        attributable to the absence or inadequacy of sanitation 
        facilities. [such systems;]
          (3) [t]The long-term cost to the United States of 
        treating and curing such disease, injury, and illness 
        is substantially greater than the short-term cost of 
        providing sanitation facilities [such systems] and 
        other preventive health measures[;].
          (4) [m]Many Indian homes and Indian communities still 
        lack sanitation facilities. [safe water supply systems 
        and sanitary sewage and solid waste disposal systems; 
        and]
          (5) [i]It is in the interest of the United States, 
        and it is the policy of the United States, that all 
        Indian communities and Indian homes, new and existing, 
        be provided with sanitation facilities. [safe and 
        adequate water supply systems and sanitary sewage waste 
        disposal systems as soon as possible.]
    (b) Facilities and Services.--[Authority; assistance; 
transfer offunds]
          [(1)] In furtherance of the findings [and 
        declarations] made in subsection (a) [of this section], 
        Congress reaffirms the primary responsibility and 
        authority of the Service to provide the necessary 
        sanitation facilities and services as provided in 
        section 7 of the Act of August 5, 1954 (42 U.S.A. 
        2004a) [2004a of Title 42]. Under such authority, [(2) 
        T]the Secretary, acting through the Service, is 
        authorized to provide the following: [under section 
        2004a of Title 42.]
          (1) [(A) f]Financial and technical assistance to 
        Indian [t]Tribes, Tribal Organizations, and Indian 
        communities in the establishment, training, and 
        equipping of utility organizations to operate and 
        maintain [Indian] sanitation facilities[;], including 
        the provision of existing plans, standard details, and 
        specifications available in the Department, to be used 
        at the option of the Indian Tribe, Tribal Organization, 
        or Indian community.
          (2) [(B) o]Ongoing technical assistance and training 
        to Indian Tribes, Tribal Organizations, and Indian 
        communities in the management of utility organizations 
        which operate and maintain sanitation facilities.[; 
        and]
          (3) [(C)] Priority funding for operation and 
        maintenance assistance for, and emergency repairs to, 
        [tribal] sanitation facilities operated by an Indian 
        Tribe, Tribal Organization or Indian community when 
        necessary to avoid an imminent [a] health hazard or to 
        protect the [Federal] investment in the health benefits 
        gained through the provision of sanitation facilities.
    (c) Funding.--[(3)] Notwithstanding any other provision of 
law--
          (1)[(A)] the Secretary of Housing and Urban 
        Development [Affairs] is authorized to transfer funds 
        appropriated under the Native American Housing 
        Assistance and Self-Determination [Community 
        Development] Act of 1996 [1974 (42 U.S.C. 5301 et 
        seq.)] to the Secretary of Health and Human Services;[, 
        and]
          (2)[(B)] the Secretary of Health and Human Services 
        is authorized to accept and use such funds for the 
        purpose of providing sanitation facilities and services 
        for Indians under section 7 of the Act of August 5, 
        1954 (42 U.S.C. 2004a); [2004a of Title 42.]
          (3) unless specifically authorized when funds are 
        appropriated, the Secretary shall not use funds 
        appropriated under section 7 of the Act of August 5, 
        1954 (42 U.S.C. 2004a), to provide sanitation 
        facilities to new homes constructed using funds 
        provided by the Department of Housing and Urban 
        Development;
          (4) the Secretary of Health and Human Services is 
        authorized to accept from any source, including Federal 
        and State agencies, funds for the purpose of providing 
        sanitation facilities and services and place these 
        funds into Funding Agreements;
          (5) except as otherwise prohibited by this section, 
        the Secretary may use funds appropriated under the 
        authority of section 7 of the Act of August 5, 1954 (42 
        U.S.C. 2004a) to fund up to 100 percent of the amount 
        of an Indian Tribe's loan obtained under any Federal 
        program for new projects to construct eligible 
        sanitation facilities to serve Indian homes;
          (6) except as otherwise prohibited by this section, 
        the Secretary may use funds appropriated under the 
        authority of section 7 of the Act of August 5, 1954 (42 
        U.S.C. 2004a) to meet matching or cost participation 
        requirements under other Federal and non-Federal 
        programs for new projects to construct eligible 
        sanitation facilities;
          (7) all Federal agencies are authorized to transfer 
        to the Secretary funds identified, granted, loaned, or 
        appropriated whereby the Department's applicable 
        policies, rules, and regulations shall apply in the 
        implementation of such projects;
          (8) the Secretary of Health and Human Services shall 
        enter into interagency agreements with Federal and 
        State agencies for the purpose of providing financial 
        assistance for sanitation facilities and services under 
        this Act; and
          (9) the Secretary of Health and Human Services shall, 
        by regulation developed through rulemaking under 
        section 802, establish standards applicable to the 
        planning, design, and construction of sanitation 
        facilities funded under this Act.
    [(c) 10-Year plan
    [Beginning in fiscal year 1990, the Secretary, acting 
through the Service, shall develop and begin implementation of 
a 10-year plan to provide safe water supply and sanitation 
sewage and solid waste disposal facilities to existing Indian 
homes and communities and to new and renovated Indian homes.]
    (d) Certain Capabilities Not Prerequisite.--[Tribal 
capability]
    The financial and technical capability of an Indian 
[t]Tribe, Tribal Organization, or Indian community to safely 
operate, manage, and maintain a sanitation facility shall not 
be a prerequisite to the provision or construction of 
sanitation facilities by the Secretary.
    (e) Financial [Amount of a]Assistance.--
    [(1)] The Secretary is authorized to provide financial 
assistance to Indian [t]Tribes, Tribal Organizations and Indian 
communities for operation, management, and maintenance of their 
sanitation facilities. [in an amount equal to the Federal share 
of the costs of operating, managing, and maintaining the 
facilities provided under the plan described in subsection (c) 
of this section.]
          [(2) For the purposes of paragraph (1), the term 
        ``Federal share'' means 80 percent of the costs 
        described in paragraph (1).
          [(3) With respect to Indian tribes with fewer than 
        1,000 enrolled members, the non-Federal portion of the 
        costs of operating, managing, and maintaining such 
        facilities may be provided, in part, through cash 
        donations or in kind property, fairly evaluated.]
    (f) Operation, Management, and Maintenance of Facilities.--
The Indian Tribe, Tribal Organization, or Indian community has 
the primary responsibility to establish, collect, and use 
reasonable user fees, or otherwise set aside funding, for the 
purpose of operating, managing, and maintaining sanitation 
facilities. If a sanitation facility serving a community that 
is operated by an Indian Tribe, Tribal Organization, or Indian 
community is threatened with imminent failure and such operator 
lacks capacity to maintain the integrity or the health benefits 
of the sanitation facility, then the Secretary is authorized to 
assist the Indian Tribe, Tribal Organization, or Indian 
community in the resolution of the problem on a short-term 
basis through cooperation with the emergency coordinator or by 
providing operation, management, and maintenance service.
    (g) ISDEAA Program Funded on Equal Basis.--Tribal Health 
Programs shall be eligible (on an equal basis with programs 
that are administered directly by the Service) for--
          (1) any funds appropriated pursuant to this section; 
        and
          (2) any funds appropriated for the purpose of 
        providing sanitation facilities.
    [(f) Eligibility of programs administered by Indian tribes
    [Programs administered by Indian tribes or tribal 
organizations under the authority of the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.] shall be 
eligible for--
          [(1) any funds appropriated pursuant to this section, 
        and
          [(2) any funds appropriated for the purpose of 
        providing water supply or sewage disposal services,
on an equal basis with programs that are administered directly 
by the Service.]
    (h) Report._(g) Annual report; sanitation deficiency 
levels
          (1) Required; Contents._The Secretary, in 
        consultation with the Secretary of Housing and Urban 
        Development, Indian Tribes, Tribal Organizations, and 
        tribally designated housing entities (as defined in 
        section 4 of the Native American Housing Assistance and 
        Self-Determination Act of 1996 (25 U.S.C. 4103)) shall 
        submit to the President, for inclusion in each report 
        required to be transmitted to [the] Congress under 
        section 801[1671 of this title], a report which sets 
        forth--
                  (A) the current Indian sanitation facility 
                priority system of the Service;
                  (B) the methodology for determining 
                sanitation deficiencies and needs;
                  (C) the level of initial and final sanitation 
                deficiency for each type of sanitation facility 
                [facilities] for each type of project of each 
                Indian [t]Tribe or Indian community;
                  (D) the amount and most effective use of 
                funds, derived from whatever source, necessary 
                to accommodate the sanitation facilities needs 
                of new homes assisted with funds under the 
                Native American Housing Assistance and Self-
                Determination Act, and to reduce the identified 
                sanitation deficiency levels of [raise] all 
                Indian [t]Tribes and Indian communities to [a] 
                level I sanitation deficiency as defined in 
                paragraph (4)(A); and
                  (E) a 10-year plan to provide sanitation 
                facilities to serve existing Indian homes and 
                Indian communities and new and renovated Indian 
                homes. [the amount of funds necessary to raise 
                all Indian tribes and communities to zero 
                sanitationdeficiency.]
          (2) Criteria.--The criteria on which the deficiencies 
        and needs will be evaluated shall be developed through 
        negotiated rulemaking pursuant to section 802.
          [(2) In preparing each report required under 
        paragraph (1) (other than the initial report), the 
        Secretary shall consult with Indian tribes and tribal 
        organization (including those tribes or tribal 
        organizations operating health care programs or 
        facilities under any contract entered into with the 
        Service under the Indian Self-Determination Act [25 
        U.S.C.A. Sec. 450f et seq.]) to determine the 
        sanitation needs of each tribe.]
          (3) Uniform methodology.--The methodology used by the 
        Secretary in determining, preparing cost estimates for, 
        and reporting sanitation deficiencies for purposes of 
        paragraph (1) shall be applied uniformly to all Indian 
        [t]Tribes and Indian communities.
          (4) Sanitation deficiency levels.--For purposes of 
        this subsection, the sanitation deficiency levels for 
        an individual, Indian [t]Tribe or Indian community 
        sanitation facility to serve Indian homes are 
        determined as follows:
                  (A) A level I deficiency exists if a 
                sanitation facility serving [is] an individual, 
                Indian [t]Tribe or Indian community [with a 
                sanitation system]--
                          (i) [which] complies with all 
                        applicable water supply, [and] 
                        pollution control, and solid waste 
                        disposal laws[,]; and
                          (ii) [in which the] deficiencies 
                        relate to routine replacement, repair, 
                        or maintenance needs[;].
                  (B) A level II deficiency exists if a 
                sanitation facility serving an individual, [is 
                an] Indian [t]Tribe, or Indian community 
                substantially or recently complied with all 
                applicable water supply, pollution control, and 
                solid waste laws and any deficiencies relate to 
                [with a sanitation system]--
                          (i) small or minor capital 
                        improvements needed to bring the 
                        facility back into compliance; [which 
                        complies with all applicable water 
                        supply and pollution control laws, and]
                          (ii) [in which the deficiencies 
                        relate to] capital improvements that 
                        are necessary to enlarge or improve the 
                        facilities in order to meet the current 
                        needs [of such tribe or community] for 
                        domestic sanitation facilities; or
                          (iii) the lack of equipment or 
                        training by an Indian Tribe, Tribal 
                        Organization, or an Indian community to 
                        properly operate and maintain the 
                        sanitation facilities.
                  (C) A level III deficiency exists if a 
                sanitation facility serving an individual, [is 
                an] Indian [t]Tribe or Indian community meets 
                one or more of the following conditions [with a 
                sanitation system which]--
                          (i) water or sewer service in the 
                        home is provided by a haul system with 
                        holding tanks and interior plumbing; 
                        [has an inadequate or partial water 
                        supply and a sewage disposal facility 
                        that does not comply with applicable 
                        water supply and pollution control 
                        laws, or]
                          (ii) major significant interruptions 
                        to water supply or sewage disposal 
                        occur frequently, requiring major 
                        capital improvements to correct the 
                        deficiencies; or [has no solid waste 
                        disposal facility;]
                          (iii) there is no access to or no 
                        approved or permitted solid waste 
                        facility available.
                  (D) A level IV deficiency exists if--[(IV) is 
                an Indian tribe or community with a sanitary 
                system which lacks either a safe water supply 
                system or a sewage disposal system: and]
                          (i) a sanitation facility of an 
                        individual, Indian Tribe, Tribal 
                        Organization, or Indian community has 
                        no piped water or sewer facilities in 
                        the home or the facility has become 
                        inoperable due to major component 
                        failure; or
                          (ii) where only a washeteria or 
                        central facility exists in the 
                        community.
                  (E) A level V deficiency exists in the 
                absence of a sanitation facility, where 
                individual homes do not have access to safe 
                drinking water or adequate wastewater 
                (including sewage) disposal. [(V) is an Indian 
                tribe or community that lacks a safe water 
                supply and a sewage disposal system.]
    (j) Definitions.--For purposes of this section, the 
following terms apply:
          (1) Indian community.--the term `Indian community' 
        means a geographic area, a significant proportion of 
        whose inhabitants are Indians and which is served by or 
        capable of being served by a facility described in this 
        section.
          (2) Sanitation facilities.--The terms `sanitation 
        facility' and `sanitation facilities' mean safe and 
        adequate water supply systems, sanitary sewage disposal 
        systems, and sanitary solid waste systems (and all 
        related equipment and support infrastructure).
          [(5) For purposes of this subsection, any Indian 
        tribe or community that lacks the operation and 
        maintenance capability to enable its sanitation system 
        to meet pollution control laws may not be treated as 
        having a level I or II sanitation deficiency.]

Sec. 1633. Preference to Indians and Indian firms

    (a) Buy Indian Act.--[Discretionary authority; covered 
activities.]
    The Secretary, acting through the Service, may use 
[utilize] the negotiating authority of section 23 [47] of the 
Act of June 25, 1910 (25 U.S.C. 47, commonly known as the `Buy 
Indian Act') [this title], to give preference to any Indian or 
any enterprise, partnership, corporation, or other type of 
business organization owned and controlled by an Indian or 
Indians including former or currently federally recognized 
Indian [t]Tribes in the State of New York (hereinafter referred 
to as an ``Indian firm'') in the construction and renovation of 
Service facilities pursuant to section 301 [1631 of this title] 
and in the construction of sanitation [safe water and sanitary 
waste disposal] facilities pursuant to section 302 [1632 of 
this title]. Such preference may be accorded by the Secretary 
unless the Secretary [he] finds, pursuant to [rules and] 
regulations [promulgated] adopted pursuant to section 802 [by 
him], that the project or function to be contracted for will 
not be satisfactory or such project or function cannot be 
properly completed or maintained under the proposed contract. 
The Secretary, in arriving at such a [his] finding, shall 
consider whether the Indian or Indian firm will be deficient 
with respect to--
          (1) ownership and control by Indians[,];
          (2) equipment[,];
          (3) bookkeeping and accounting procedures[,];
          (4) substantive knowledge of the project or function 
        to be contracted for[,];
          (5) adequately trained personnel[,]; or
          (6) other necessary components of contract 
        performance.
    (b) Labor Standards.--[Pay rates]
          (1) In general.--For the purpose of implementing the 
        provisions of this title [subchapter], contracts for 
        the construction or renovation of health care 
        facilities, staff quarters, and sanitation facilities, 
        and related support infrastructure, funded in whole or 
        in part with funds made available pursuant to this 
        title, shall contain a provision requiring compliance 
        with subchapter IV of chapter 31 of title 40, United 
        States Code (commonly known as the `Davis-Bacon Act'), 
        unless such construction or renovation--[the secretary 
        shall assure that the rates of pay for personnel 
        engaged in the construction or renovation of facilities 
        constructed or renovated in whole or in part by funds 
        made available pursuant to this subchapter are not less 
        than the prevailing local wage rates for similar work 
        as determined in accordance with sections 3141 to 3144, 
        3146, 3147 of Title 40.]
                  (A) is performed by a contractor pursuant to 
                a contract with an Indian Tribe or Tribal 
                Organization with funds supplied through a 
                contract, compact or funding agreement 
                authorized by the Indian Self-Determination and 
                Education Assistance Act, or other statutory 
                authority; and
                  (B) is subject to prevailing wage rates for 
                similar construction or renovation in the 
                locality as determined by the Indian Tribes or 
                Tribal Organizations to be served by the 
                construction or renovation.
          (2) Exception.--This subsection shall not apply to 
        construction or renovation carried out by an Indian 
        Tribe or Tribal Organization with its own employees.

Sec. 1634. Expenditure of [n]Non[-S]service [f]Funds for [r]Renovation

    (a) In General.--[Authority of Secretary]
    [(1)] Notwithstanding any other provision of law, if the 
requirements of subsection (c) are met, the Secretary, acting 
through the Service, is authorized to accept any major 
expansion, renovation or modernization by any Indian [t]Tribe 
or Tribal Organization of any Service facility, or of any other 
Indian health facility operated pursuant to a Funding 
Agreement, [contract entered into under the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.]] including--
          (1)[(A)] any plans or designs for such expansion, 
        renovation or modernization; and
          (2)[(B)] any expansion, renovation or modernization 
        for which funds appropriated under any Federal law were 
        lawfully expended. [, but only if the requirements of 
        subsection (b) of this section are met.]
    (b) Priority List.--
          (1)[(2)] In general.--The Secretary shall maintain a 
        separate priority list to address the needs for 
        increased operating expenses, [of such facilities for] 
        personnel, or equipment for such facilities. The 
        methodology for establishing priorities shall be 
        developed through negotiated rulemaking under section 
        802. The list of priority facilities will be revised 
        annually in consultation with Indian Tribes and Tribal 
        Organizations.
          (2)[(3)] Report.--The Secretary shall submit to the 
        President, for inclusion in each report required to be 
        transmitted to [the] Congress under section 801 [1671 
        of this section], the priority list maintained pursuant 
        to paragraph (1)[(2)].
    (c)[(b)] Requirements
    The requirements of this subsection are met with respect to 
any expansion, renovation or modernization if--
          (1) the Indian T[t]ribe or [t]Tribal 
        [o]Organization--
                  (A) provides notice to the Secretary of its 
                intent to expand, renovate or modernize; and
                  (B) applies to the Secretary to be place on a 
                separate priority list to address the needs of 
                such new facilities for increased operating 
                expenses, personnel or equipment; and
          (2) the expansion, renovation or modernization--
                  (A) is approved by the appropriate area 
                director of the Service for Federal facilities; 
                and
                  (B) is administered by the Indian T[t]ribe or 
                Tribal Organization in accordance with any 
                applicable [the rules and] regulations 
                prescribed by the Secretary with respect to 
                construction or renovation of Service 
                facilities.
    (d) Additional Requirement for Expansion.--In addition to 
the requirements in subsection (c), for any expansions, the 
Indian Tribe or Tribal Organization shall provide to the 
Secretary additional information developed through negotiated 
rulemaking under section 802, including additional staffing, 
equipment, and other costs associated with the expansion.
    (e) Closure or Conversion of Facilities.--[(c) Recovery for 
non-use as Service facility]
    If any Service facility which has been expanded, renovated 
or modernized by an Indian [t]Tribe or Tribal Organization 
under this section ceases to be used as a Service facility 
during the 20-year period beginning on the date such expansion, 
renovation or modernization is completed, such Indian [t]Tribe 
or Tribal Organization shall be entitled to recover from the 
United States an amount which bears the same ratio to the value 
of such facility at the time of such cessation as the value of 
such expansion, renovation or modernization (less the total 
amount of any funds provided specifically for such facility 
under any Federal program that were expended for such 
expansion, renovation or modernization) bore to the value of 
such facility at the time of the completion of such expansion, 
renovation or modernization.

[Sec. 1635. Repealed. Pub.L. 100-713, Title III, Sec. 303(b), Nov. 23, 
                    1988, 102 Stat. 4817]

Sec. 1636. Funding [Grant program] for the [c]Construction, 
                    [e]Expansion, and [m]Modernization of [s]Small 
                    [a]Ambulatory [c]Care [f]Facilities

    (a) Funding.--[Authorization]
          (1) In general.--The Secretary, acting through the 
        Service, in consultation with Indian Tribes and Tribal 
        Organizations, shall make funding available [grants] to 
        Indian T[t]ribes and [t]Tribal [o]Organizations for the 
        construction, expansion, or modernization of facilities 
        for the provision of ambulatory care services to 
        eligible Indians (and noneligible persons pursuant to 
        subsections (b)(2) and (c)(1)(C) [as provided in 
        subsection (c)(1)(C) of this section)]. Funding [A 
        grant] made under this section may cover up to 100 
        percent of the costs of such construction, expansion, 
        or modernization. For the purposes of this section, the 
        term [``]`construction'[''] includes the replacement of 
        an existing facility.
          (2) Funding Agreement Required.--Funding [A grant] 
        under paragraph (1) may only be available [made] to a 
        Tribal HealthProgram [tribe or tribal organization] 
operating an Indian health facility (other than a facility owned or 
constructed by the Service, including a facility originally owned or 
constructed by the Service and transferred to a Indian T[t]ribe or 
[t]Tribal [o]Organization) [pursuant to a contract entered into under 
the Indian Self-Determination Act [25 U.S.C.A. Sec. 450f et seq.]].
    (b) Use of Funds [grant]
          (1) Allowable uses.--Funding [A grant] provided under 
        this section may be used [only] for the construction, 
        expansion, or modernization (including the planning and 
        design of such construction, expansion, or 
        modernization) of an ambulatory care facility--
                  (A) located apart from a hospital;
                  (B) not funded under section 301[1631] or 
                section 307[1637 of this title]; and
                  (C) which, upon completion of such 
                construction, expansion, or modernization 
                will--
                          (i) have a total capacity appropriate 
                        to its projected service population;
                          (ii) provide annually no fewer than 
                        150 eligible Indians and other users 
                        who are eligible for services in such 
                        facility in accordance with section 
                        807(c)(2) [serve no less than 500 
                        eligible Indians annually]; and
                          (iii) provide ambulatory care in a 
                        [s]Service [a]Area (specified in the 
                        Funding Agreement [contract entered 
                        into under the Indian Self-
                        Determination Act [25 U.S.C.A. 
                        Sec. 450f et seq.]]) with a population 
                        of no fewer than 1,500 [not less than 
                        2,000] eligible Indians and other users 
                        who are eligible for services in such 
                        facility in accordance with section 
                        807(c)(2).
          (2) Additional allowable use.--The Secretary may also 
        reserve a portion of the funding provided under this 
        section and use those reserved funds to reduce an 
        outstanding debt incurred by Indian Tribes or Tribal 
        Organizations for the construction, expansion, or 
        modernization of an ambulatory care facility that meets 
        the requirements under paragraph (1). The provisions of 
        this section shall apply, except that such applications 
        for funding under this paragraph shall be considered 
        separately from applications for funding under 
        paragraph (1).
          (3) Use only for certain portion of costs.--Funding 
        provided under this section may be used only for the 
        cost of that portion of a construction, expansion, or 
        modernization project or debt reduction that benefits 
        the Service population identified above in subsection 
        (b)(1)(C)(ii) and (iii).
          (4) Applicability of requirements in the case of 
        isolated facilities.--[(2)] The requirements of clauses 
        (ii) and (iii) of paragraph (1)(C) shall not apply to 
        an Indian Tribe [a tribe] or [t]Tribal [o]Organization 
        applying for funding [a grant] under this section for a 
        health care facility [whose tribal government offices 
        are] located or to be constructed on an island or when 
        such facility is not located on a road system providing 
        direct access to an inpatient hospital where care is 
        available to the Service population.
    (c) Funding.--[Application for grant]
          (1) Application.--No funding [grant] may be made 
        available under this section unless an application or 
        proposal for such funding has been [a grant has been 
        submitted to and] approved by the Secretary in 
        accordance with applicable regulations and has provided 
        reasonable assurance by the applicant that, at all 
        times after the construction, expansion, or 
        modernization of a facility carried out pursuant to 
        funding received under this section--[. An application 
        for a grant under this section shall be submitted in 
        such form and manner as the Secretary shall by 
        regulation prescribe and shall set forth reasonable 
        assurance by the applicant that, at all times after the 
        construction, expansion, or modernization of a facility 
        carried out pursuant to a grant received under this 
        section--]
                  (A) adequate financial support will be 
                available for the provision of services at such 
                facility;
                  (B) such facility will be available to 
                eligible Indians without regard to ability to 
                pay or source of payment; and
                  (C) such facility will, as feasible without 
                diminishing the quality or quantity of services 
                provided to eligible Indians, serve noneligible 
                persons on a cost basis.
          (2) Priority.--In awarding funding [grants] under 
        this section, the Secretary shall give priority to 
        Indian T[t]ribes and [t]Tribal [o]Organizations that 
        demonstrate--
                  (A) a need for increased ambulatory care 
                services; and
                  (B) insufficient capacity to deliver such 
                services.
          (3) Peer review panels.--The Secretary may provide 
        for the establishment of peer review panels, as 
        necessary, to review and evaluate applications and 
        proposals and to advise the Secretary regarding such 
        applications using the criteria developed during 
        consultations pursuant to subsection (a)(1).
    (d) Reversion of Facilities.--[Transfer of interest to 
united states upon cessation of facility]
    If any facility (or portion thereof) with respect to which 
funds have been paid under this section, ceases, within 5 years 
[at any time] after completion of the construction, expansion, 
or modernization carried out with such funds, to be used 
[utilized] for the purposes of providing health [ambulatory] 
care services to eligible Indians, all of the right, title, and 
interest in and to such facility (or portion thereof) shall 
transfer to the United States unless otherwise negotiated by 
the Service and the Indian Tribe or Tribal Organization.
    (e) Funding Nonrecurring.--Funding provided under this 
section shall be nonrecurring and shall not be available for 
inclusion in any individual Indian Tribe's tribal share for an 
award under the Indian Self-Determination and Education 
Assistance Act or for reallocation or redesign thereunder.

Sec. 1637. Indian [h]Health [c]Care [d]Delivery [d]Demonstration 
                    [p]Project

    (a) Health [c]Care [delivery d]Demonstration [p]Projects.--
    The Secretary, acting through the Service, and in 
consultation with Indian Tribes and Tribal Organizations, is 
authorized to enter into construction project agreements and 
construction contracts under the Indian Self-Determination and 
Education Assistance Act (25 U.S.C. 450 et seq.) with[, or make 
grants to,] Indian [t]Tribes or [t]Tribal [o]Organizations for 
the purpose of carrying out a health care delivery 
demonstration project to test alternative means of delivering 
health care and services through [health] facilities, including 
but not limited to hospice, traditional Indian health, and 
child care facilities [to Indians].
    (b) Use of [f]Funds
    The Secretary, in approving projects pursuant to this 
section, may authorize funding for the construction and 
renovation of hospitals, health centers, health stations, and 
other facilities to deliver health care services and is 
authorized to--
          (1) waive any leasing prohibition;
          (2) permit carryover of funds appropriated for the 
        provision of health care services;
          (3) permit the use of other available [non-Service 
        Federal funds and non-Federal] funds;
          (4) permit the use of funds or property donated from 
        any source for project purposes; [and]
          (5) provide for the reversion of donated real or 
        personal property to the donor[.]; and
          (6) permit the use of Service funds to match other 
        funds, including Federal funds.
    (c) Regulations.--[Criteria]
    [(1) Within 180 days after November 28, 1990, t]The 
Secretary[, after consultation with Indian tribes and tribal 
organizations,] shall develop and promulgate regulations not 
later than 1 year after the enactment of the Indian Health Care 
Improvement Act Amendments of 2004. If the Secretary has not 
promulgated regulations by that date, the Secretary shall 
develop and publish regulations, through rulemaking under 802, 
[in the Federal Register criteria] for the review and approval 
of applications submitted under this section.
    (d) Criteria.--The Secretary may approve [enter into a 
contract or award a grant under this section for] projects that 
[which] meet the following criteria:
          (1)[(A)] There is a need for a new facility or 
        program or the reorientation of an existing facility or 
        program.
          (2)[(B)] A significant number of Indians, including 
        those with low health status, will be served by the 
        project.
                  [(C) The project has the potential to address 
                the health needs of Indians in an innovative 
                manner.]
          (3)[(D)] The project has the potential to deliver 
        services in an efficient and effective manner.
          (4)[(E)] The project is economically viable.
          (5)[(F)] The Indian [t]Tribe or [t]Tribal 
        [o]Organization has the administrative and financial 
        capability to administer the project.
          (6)[(G)] The project is integrated with providers of 
        related health and social services and is coordinated 
        with, and avoids duplication of, existing services.
    (e) Peer Review Panels.--[(2)] The Secretary may provide 
for the establishment of peer review panels, as necessary, to 
review and evaluate applications [and to advise the Secretary 
regarding such applications] using the criteria developed 
pursuant to subsection (d) [paragraph (1)].
    (f) Priority.--The Secretary shall give priority to 
applications for demonstration projects [(3)(A) On or before 
September 30, 1995, the Secretary shall enter into contracts or 
award grants under this section for a demonstration project] in 
each of the following [s]Service [u]Units to the extent that 
such applications are timely filed and meet the criteria 
specified in subsection (d): [which meets the criteria 
specified in paragraph (1) and for which a completed 
application has been received by the Secretary:]
          (1)[(i)] Cass Lake, Minnesota.
          (2)[(ii)] Clinton, Oklahoma.
          (3)[(iii)] Harlem, Montana.
          (4)[(iv)] Mescalero, New Mexico
          (5)[(v)] Owyhee, Nevada.
          (6)[(vi)] Parker, Arizona.
          (7)[(vii)] Schurz, Nevada.
          (8)[(viii)] Winnebago, Nebraska.
          (9)[(ix)] Ft. Yuma, California.
                  [(B) The Secretary may also enter into 
                contracts or award grants under this section 
                taking into consideration applications received 
                under this section from all service areas. The 
                Secretary may not award a greater number of 
                such contracts or grants in one service area 
                than in any other service area until there is 
                an equal number of such contracts or grants 
                awarded with respect to all service areas from 
                which the Secretary receives applications 
                during the application period (as determined by 
                the Secretary) which meet the criteria 
                specified in paragraph (1).]
    (g)[(d)] Technical [a]Assistance.--
    The Secretary shall provide such technical and other 
assistance as may be necessary to enable applicants to comply 
with the provisions of this section.
    (h)[(e)] Service to [i]Ineligible [p]Persons.--
    The authority to provide services to persons otherwise 
ineligible for the health care benefits of the Service and the 
authority to extend hospital privileges in [s]Service 
facilities to non-Service health care practitioners as provided 
in section 807[1680c of this title] may be included, subject to 
the terms of such section, in any demonstration project 
approved pursuant to this section.
    (i)[(f)] Equitable [t]Treatment.--
    For purposes of subsection (d)(1)[(c)(1)(A) of this 
section], the Secretary shall, in evaluating facilities 
operated under any Funding Agreement, [contract entered into 
with the Service under the Indian Self-Determination Act [25 
U.S.C.A. Sec. 450f et seq.],] use the same criteria that the 
Secretary uses in evaluating facilities operated directly by 
the Service.
    (j)[(g)] Equitable [i]Integration of [f]Facilities.--
    The Secretary shall ensure that the planning, design, 
construction, [and] renovation, and expansion needs of Service 
and non-Service facilities which are the subject of a Funding 
Agreement [contract] for health services [entered into with the 
Service under the Indian Self-Determination Act [25 U.S.C.A. 
450f et seq.],] are fully and equitably integrated into the 
implementation of the health care delivery demonstration 
projects under this section.
    [(h) Report to Congress
          [(1) The Secretary shall submit to the President, for 
        inclusion in the report which is required to be 
        submitted to the Congress under section 1671 of this 
        title for fiscal year 1997, an interim report on the 
        findings and conclusions derived from the demonstration 
        projects established under this section.
          [(2) The Secretary shall submit to the President, for 
        inclusion in the report which is required to be 
        submitted to the Congress under section 1671 of this 
        title for fiscal year 1999, a final report on the 
        findings and conclusions derived from the demonstration 
        projects established under this section, together with 
        legislative recommendations.]

Sec. 1638. Land [t]Transfer

    Notwithstanding any other provision of law, [T]the Bureau 
of Indian Affairs and all other agencies and departments of the 
United States are [is] authorized to transfer, at no cost, land 
and improvements to the Service for the provision of health 
care services. The Secretary is authorized to accept such land 
and improvements for such purposes. [up to 5 acres of land at 
the Chemawa Indian School, Salem, Oregon, to the Service for 
the provision of health care services. The land authorized to 
be transferred by this section is that land adjacent to land 
under the jurisdiction of the Service and occupied by the 
Chemawa Indian Health Center.]

Sec. 308. Leases, Contracts, and Other Agreements

    The Secretary, acting through the Service, may enter into 
leases, contracts, and other agreements with Indian Tribes and 
Tribal Organization which hold (1) title to, (2) a leasehold 
interest in, or (3) a beneficial interest in (when title is 
held by the United States in trust for the benefit of an Indian 
Tribe) facilities used or to be used for the administration and 
delivery of health services by an Indian Health Program. Such 
leases, contracts, or agreements may include provisions for 
construction or renovation and provide for compensation to the 
Indian Tribe or Tribal Organization of rental and other costs 
consistent with section 105(l) of the Indian Self-Determination 
and Education Assistance Act and regulations thereunder. 
Notwithstanding any other provision of law, such leases, 
contracts, or other agreements shall be considered as operating 
leases for the purpose of scoring under the Balanced Budget and 
Emergency Deficit Control Act of 1985 (2 U.S.C. 901 et seq.).

Sec. 309. Study on Loans, Loan Guarantees, and Loan Repayment

    (a) In General.--The Secretary, in consultation with the 
Secretary of the Treasury, Indian Tribes, and Tribal 
Organizations, shall carry out a study to determine the 
feasibility of establishing a loan fund to provide to Indian 
Tribes and Tribal Organizations direct loans or guarantees for 
loans for the construction of health care facilities, 
including--
          (1) inpatient facilities;
          (2) outpatient facilities;
          (3) staff quarters;
          (4) hostels; and
          (5) specialized care facilities, such as behavioral 
        health and elder care facilities.
    (b) Determinations.--In carrying out the study under 
subsection (a), the Secretary shall determine--
          (1) the maximum principal amount of a loan or loan 
        guarantee that should be offered to a recipient from 
        the loan fund;
          (2) the percentage of eligible costs, not to exceed 
        100 percent, that may be covered by a loan or loan 
        guarantee from the loan fund (including costs relating 
        to planning, design, financing, site land development, 
        construction, rehabilitation, renovation, conversion, 
        improvements, medical equipment and furnishings, and 
        other facility-related costs and capital purchase (but 
        excluding staffing));
          (3) the cumulative total of the principal of direct 
        loans and loan guarantees, respectively, that may be 
        outstanding at any 1 time;
          (4) the maximum term of a loan or loan guarantee that 
        may be made for a facility from the loan fund;
          (5) the maximum percentage of funds from the loan 
        fund that should be allocated for payment of costs 
        associated with planning and applying for a loan or 
        loan guarantee;
          (6) whether acceptance by the Secretary of an 
        assignment of the revenue of an Indian Tribe or Tribal 
        Organization as security for any direct loan or loan 
        guarantee from the loan fund would be appropriate;
          (7) whether, in the planning and design of health 
        facilities under this section, users eligible under 
        section 807(c) may be included in any projection of 
        patient population;
          (8) whether funds of the Service provided through 
        loans or loan guarantees from the loan fund should be 
        eligible for use in matching other Federal funds under 
        other programs;
          (9) the appropriateness of, and best methods for, 
        coordinating the loan fund with the health care 
        priority system of the Service under section 301; and
          (10) any legislative or regulatory changes required 
        toimplement recommendations of the Secretary based on 
results of the study.
    (c) Report.--Not later than September 30, 2006, the 
Secretary shall submit to the Committee on Indian Affairs of 
the Senate and the Committee on Resources and the Committee on 
Energy and Commerce of the House of Representatives a report 
that describes--
          (1) the manner of consultation made as required by 
        subsection (a); and
          (2) the results of the study, including any 
        recommendations of the Secretary based on results of 
        the study.

Sec. 310. Tribal Leasing

    A Tribal Health Program may lease permanent structures for 
the purpose of providing health care services without obtaining 
advance approval in appropriation Acts.

Sec. 311. Indian Health Service/Tribal Facilities Joint Venture Program

    (a) In General.--The Secretary, acting through the Service, 
is authorized to negotiate and enter into arrangements with 
Indian Tribes and Tribal Organizations to establish joint 
venture demonstration projects under which an Indian Tribe or 
Tribal Organization shall expend tribal, private, or other 
available funds, for the acquisition or construction of a 
health facility for a minimum of 10 years, under a no-cost 
lease, in exchange for agreement by the Service to provide the 
equipment, supplies, and staffing for the operation and 
maintenance of such a health facility. An Indian Tribe or 
Tribal Organization may use tribal funds, private sector, or 
other available resources, including loan guarantees, to 
fulfill its commitment under a joint venture entered into under 
this subsection. An Indian Tribe or Tribal Organization shall 
be eligible under this section if, when it submits a letter of 
intent, it--
          (1) has begun but not completed the process of 
        acquisition or construction of a health facility to be 
        used in the joint venture project; or
          (2) has not begun the process of acquisition or 
        construction of a health facility for use in the joint 
        venture project.
    (b) Requirements.--The Secretary shall make such an 
arrangement with an Indian Tribe or Tribal Organization only 
if--
          (1) the Secretary first determines that the Indian 
        Tribe or Tribal Organization has the administrative and 
        financial capabilities necessary to complete the timely 
        acquisition or construction of the relevant health 
        facility; and
          (2) the Indian Tribe or Tribal Organization meets the 
        need criteria which shall be developed through the 
        negotiated rulemaking process provided for under 
        section 802.
    (c) Continued Operation.--The Secretary shall negotiate an 
agreement with the Indian Tribe or Tribal Organization 
regarding the continued operation of the facility at the end of 
the initial 10 year no-cost lease period.
    (d) Breach of Agreement.--An Indian Tribe or Tribal 
Organization that has entered into a written agreement with the 
Secretary under this section, and that breaches or terminates 
without cause such agreement, shall be liable to the United 
States for the amount that has been paid to the Indian Tribe or 
Tribal Organization, or paid to a third party on the Indian 
Tribe's or Tribal Organization's behalf, under the agreement. 
The Secretary has the right to recover tangible property 
(including supplies) and equipment, less depreciation, and any 
funds expended for operations and maintenance under this 
section. The preceding sentence does not apply to any funds 
expended for the delivery of health care services, personnel, 
or staffing.
    (e) Recovery for Nonuse.--An Indian Tribe or Tribal 
Organization that has entered into a written agreement with the 
Secretary under this subsection shall be entitled to recover 
from the United States an amount that is proportional to the 
value of such facility if, at any time within the 10-year term 
of the agreement, the Service ceases to use the facility or 
otherwise breaches the agreement.
    (f) Definition.--For the purposes of this section, the term 
`health facility' or `health facilities' includes quarters 
needed to provide housing for staff of the relevant Tribal 
Health Program.

Sec. 312. Location of Facilities

    (a) In General.--In all matters involving the 
reorganization or development of Service facilities or in the 
establishment of related employment projects to address 
unemployment conditions in economically depressed areas, the 
Bureau of Indian Affairs and the Service shall give priority to 
locating such facilitiesand projects on Indian lands if 
requested by the Indian owner and the Indian Tribe with jurisdiction 
over such lands or other lands owned or leased by the Indian Tribe or 
Tribal Organization. Top priority shall be given to Indian land owned 
by 1 or more Indian Tribes.
    (b) Definition.--For purposes of this section, the term 
`Indian lands' means--
          (1) all lands within the exterior boundaries of any 
        reservation;
          (2) any lands title to which is held in trust by the 
        United States for the benefit of any Indian Tribe or 
        individual Indian or held by any Indian Tribe or 
        individual Indian subject to restriction by the United 
        States against alienation; and
          (3) all lands in Alaska owned by any Alaska Native 
        village, or village or regional corporation under the 
        Alaska Native Claims Settlement Act, or any land 
        allotted to any Alaska Native.

Sec. 313. Maintenance and Improvement of Health Care Facilities

    (a) Report.--The Secretary shall submit to the President, 
for inclusion in the report required to be transmitted to 
Congress under section 801, a report which identifies the 
backlog of maintenance and repair work required at both Service 
and tribal health care facilities, including new health care 
facilities expected to be in operation in the next fiscal year. 
The report shall also identify the need for renovation and 
expansion of existing facilities to support the growth of 
health care programs.
    (b) Maintenance of Newly Constructed Space.--The Secretary, 
acting through the Service, is authorized to expend maintenance 
and improvement funds to support maintenance of newly 
constructed space only if such space falls within the approved 
supportable space allocation for the Indian Tribe or Tribal 
Organization. Supportable space allocation shall be defined 
through the negotiated rulemaking process provided for under 
section 802.
    (c) Replacement Facilities.--In addition to using 
maintenance and improvement funds for renovation, 
modernization, and expansion of facilities, an Indian Tribe or 
Tribal Organization may use maintenance and improvement funds 
for construction of a replacement facility if the costs of 
renovation of such facility would exceed a maximum renovation 
cost threshold. The maximum renovation cost threshold shall be 
determined through the negotiated rulemaking process provided 
for under section 802.

Sec. 314. Tribal Management of Federally Owned Quarters

    (a) Rental Rates.--
          (1) Establishment.--Notwithstanding any other 
        provision of law, a Tribal Health Program which 
        operates a hospital or other health facility and the 
        federally owned quarters associated therewith pursuant 
        to a Funding Agreement shall have the authority to 
        establish the rental rates charged to the occupants of 
        such quarters by providing notice to the Secretary of 
        its election to exercise such authority.
          (2) Objectives.--In establishing rental rates 
        pursuant to authority of this subsection, a Tribal 
        Health Program shall endeavor to achieve the following 
        objections:
                  (A) To base such rental rates on the 
                reasonable value of the quarters to the 
                occupants thereof.
                  (B) To generate sufficient funds to prudently 
                provide for the operation and maintenance of 
                the quarters, and subject to the discretion of 
                the Tribal Health Program, to supply reserve 
                funds for capital repairs and replacement of 
                the quarters.
          (3) Equitable funding.--Any quarters whose rental 
        rates are established by a Tribal Health Program 
        pursuant to this subsection shall remain eligible for 
        quarters improvement and repair funds to the same 
        extent as all federally owned quarters used to house 
        personnel in Services-supported programs.
          (4) Notice of rate change.--A Tribal Health Program 
        which exercises the authority provided under this 
        subsection shall provide occupants with no less than 60 
        days notice of any change in rental rates.
    (b) Direct Collection of Rent.--
          (1) In general.--Notwithstanding any other provision 
        of law, and subject to paragraph (2), a Tribal Health 
        Program shall have the authority to collect rents 
        directly from Federal employees who occupy such 
        quarters in accordance with the following:
                  (A) The Tribal Health Program shall notify 
                the Secretary and the subject Federal employees 
                of its election toexercise its authority to 
collect rents directly from such Federal employees.
                  (B) Upon receipt of a notice described in 
                subparagraph (A), the Federal employees shall 
                pay rents for occupancy of such quarters 
                directly to the Tribal Health Program and the 
                Secretary shall have no further authority to 
                collect rents from such employees through 
                payroll deduction or otherwise.
                  (C) Such rent payments shall be retained by 
                the Tribal Health Program and shall not be made 
                payable to or otherwise be deposited with the 
                United States.
                  (D) Such rent payments shall be deposited 
                into a separate account which shall be used by 
                the Tribal Health Program for the maintenance 
                (including capital repairs and replacement) and 
                operation of the quarters and facilities as the 
                Tribal Health Program shall determine.
          (2) Retrocession of authority.--If a Tribal Health 
        Program which has made an election under paragraph (1) 
        requests retrocession of its authority to directly 
        collect rents from Federal employees occupying 
        federally owned quarters, such retrocession shall 
        become effective on the earlier of--
                  (A) the first day of the month that begins no 
                less than 180 days after the Tribal Health 
                Program notifies the Secretary of its desire to 
                retrocede; or
                  (B) such other date as may be mutually agreed 
                by the Secretary and the Tribal Health Program.
    (c) Rates in Alaska.--To the extent that a Tribal Health 
Program, pursuant to authority granted in subsection (a), 
establishes rental rates for federally owned quarters provided 
to a Federal employee in Alaska, such rents may be based on the 
cost of comparable private rental housing in the nearest 
established community with a year-round population of 1,500 or 
more individuals.

[Sec. 1638a. Authorization of appropriations

    [There are authorized to be appropriated such sums as may 
be necessary for each fiscal year through fiscal year 2000 to 
carry out this subchapter.]

Sec. 1638b. Applicability of Buy American Act R[r]equirement

    (a) Applicability.--[Duty of Secretary]
    The Secretary shall ensure that the requirements of the Buy 
American Act [[41 U.S.C.A. Sec. 10a et seq.]] apply to all 
procurements made with funds provided pursuant to [the 
authorization contained in] section 317[1638a of this title]. 
Indian Tribes and Tribal Organizations shall be exempt from 
these requirements.
    [(b) Report to Congress
    [The Secretary shall submit to the Congress a report on the 
amount of procurements from foreign entities made in fiscal 
years 1993 and 1994 with funds provided pursuant to the 
authorization contained in section 1638a of this title. Such 
report shall separately indicate the dollar value of items 
procured with such funds for which the Buy American Act [41 
U.S.C.A. Sec. 10a et seq.] was waived pursuant to the Trade 
Agreement Act of 1979 [19 U.S.C.A. Sec. 2501 et seq.] or any 
international agreement to which the United States is a party.]
    (b) [(c)] Effect of Violation.--[Fraudulent use of Made-in-
America label]
    If it has been finally determined by a court or Federal 
agency that any person intentionally affixed a label bearing a 
[``]`Made in America'[''] inscription[,] or any inscription 
with the same meaning, to any product sold in or shipped to the 
United States that is not made in the United States, such 
person shall be ineligible to receive any contract or 
subcontract made with funds provided pursuant to [the 
authorization contained in] section 317[1638a of this title], 
pursuant to the debarment, suspension, and ineligibility 
procedures described in sections 9.400 through 9.409 of title 
48, Code of Federal Regulations.
    (c) [(d)] Definitions.--[``Buy American Act'' defined]
    For purposes of this section, the term [``]`Buy American 
Act'[''] means title III of the Act entitled ``An Act making 
appropriations for the Treasury and Post Office Departments for 
the fiscal year ending June 30, 1934, and for other purposes'', 
approved March 3, 1933 (41 U.S.C. 10a et seq.).

Sec. 316. Other Funding For Facilities

    (a) Authority To Accept Funds.--The Secretary is authorized 
to accept from any source, including Federal and State 
agencies, funds that are available for the construction of 
health care facilities and use such funds to plan, design, and 
construct health care facilities for Indians and to transfer 
such funds to Indian Tribes or Tribal Organizations through 
constructionproject agreements or construction contracts under 
the Indian Self-Determination and Education Assistance Act (25 U.S.C. 
450 et seq.). Receipt of such funds shall have no effect on the 
priorities established pursuant to section 301.
    (b) Interagency Agreements.--The Secretary is authorized to 
enter into interagency agreements with other Federal agencies 
or State agencies and other entities and to accept funds from 
such Federal or State agencies or other sources to provide for 
the planning, design, and construction of health care 
facilities to be administered by Indian Health Programs in 
order to carry out the purposes of this Act and the purposes 
for which the funds were appropriated or for which the funds 
were otherwise provided.
    (c) Transferred Funds.--Any Federal agency to which funds 
for the construction of health care facilities are appropriated 
is authorized to transfer such funds to the Secretary for the 
construction of health care facilities to carry out the 
purposes of this Act as well as the purposes for which such 
funds are appropriated to such other Federal agency.
    (d) Establishment of Standards.--The Secretary, through the 
Service, shall establish standards by regulation, developed by 
rulemaking under section 802, for the planning, design, and 
construction of health care facilities serving Indians under 
this Act.

Sec. 317. Authorization of Appropriations

    There are authorized to be appropriated such sums as may be 
necessary for each fiscal year through fiscal year 2015 to 
carry out this title.

[Sec. 1638c. Contracts for personal services in Indian Health Service 
                    facilities

    [In fiscal year 1995 and thereafter--
    [(a) In general
    [The Secretary may enter into personal services contracts 
with entities, either individuals or organizations, for the 
provision of services in facilities owned, operated or 
constructed under the jurisdiction of the Indian Health 
Service.
    [(b) Exemption from competitive contracting requirements
    [The Secretary may exempt such a contract from competitive 
contracting requirements upon adequate notice of contracting 
opportunities to individuals and organizations residing in the 
geographic vicinity of the health facility.
    [(c) Consideration of individuals and organizations
    [Consideration of individuals and organizations shall be 
based solely on the qualifications established for the contract 
and the proposed contract price.
    [(d) Liability
    [Individuals providing health care services pursuant to 
these contracts are covered by the Federal Tort Claims Act.

[Sec. 1638d. Credit to appropriations of money collected for meals at 
                    Indian Health Service facilities

    [Money before, on, and after September 30, 1994, collected 
for meals served at Indian Health Service facilities will be 
credited to the appropriations from which the services were 
furnished and shall be credited to the appropriation when 
received.]

         TITLE IV [SUBCHAPTER III-A]--ACCESS TO HEALTH SERVICES

Sec. 1641. Treatment of [p]Payments [u]Under Social Security Act Health 
                    Care [medicare] P[p]rograms

    (a) Disregard of Medicare, Medicaid, and SCHIP Payments in 
Determining Appropriations [Determination of appropriations]
    Any payments received by an Indian Health Program or by an 
Urban Indian Organization made under title XVIII, XIX, or XXI 
of the Social Security Act [a hospital or skilled nursing 
facility of the Service (whether operated by the Service or by 
an Indian tribe or tribal organization pursuant to a contract 
under the Indian Self-Determination Act [25 U.S.C.A.Sec. 450f 
et seq.])] for services provided to Indians eligible for 
benefits under such respective titles [Title XVIII of the 
Social Security Act [42 U.S.C.A. Sec. 1395 et seq.]] shall not 
be considered in determining appropriations for the provision 
of health care and services to Indians.
    (b) Nonpreferential Treatment.--[Preferences]
    Nothing in this Act [chapter] authorizes the Secretary to 
provide services to an Indian [beneficiary] with coverage 
undertitle XVIII, XIX, or XXI of the Social Security Act [[42 U.S.C.A. 
Sec. 1395 et seq.], as amended,] in preference to an Indian 
[beneficiary] without such coverage.

[Sec. 1642. Treatment of payments under medicaid program]

    (c)[(a)] Use of Funds.--[Payments to special fund]
          (1) Special fund.--Notwithstanding any other 
        provision of law, but subject to paragraph (2), 
        payments to which a[ny] facility of the Service 
        [(including a hospital, nursing facility, intermediate 
        care facility for the mentally retarded, or any other 
        type of facility which provides services for which 
        payment is available under Title XIX of the Social 
        Security Act [42 U.S.C.A. Sec. 1396 et seq.])] is 
        entitled [under a State plan] by reason of a provision 
        of the Social Security Act [section 1911 of such Act 
        [42 U.S.C.A. Sec. 1396j]] shall be placed in a special 
        fund to be held by the Secretary and first used [by 
        him] (to such extent or in such amounts as are provided 
        in appropriation Acts) [exclusively] for the purpose of 
        making any improvements in the programs [facilities] of 
        the [such] Service which may be necessary to achieve or 
        maintain compliance with the applicable conditions and 
        requirements of [such] titles XVIII, XIX, and XXI of 
        the Social Security Act. Any amounts to be reimbursed 
        that are in excess of the amounts necessary to achieve 
        or maintain such conditions and requirements shall, 
        subject to the consultation with Indian Tribes being 
        served by the Service Unit, be used for reducing the 
        health resource deficiencies of the Indian Tribes. In 
        making payments from such fund, the Secretary shall 
        ensure that each [s]Service [u]Unit of the Service 
        receives 100 [at least 80] percent of the amount[s] to 
        which the facilities of the Service, for which such 
        [s]Service [u]Unit makes collections, are entitled by 
        reason of a provision [section 1911] of the Social 
        Security Act [[42 U.S.C.A. Sec. 1396j]].
          (2) Direct payment option.--Paragraph (1) shall not 
        apply upon the election of a Tribal Health Program 
        under subsection (d) to receive payments directly. No 
        payment may be made out of the special fund described 
        in such paragraph with respect to reimbursement made 
        for services provided during the period of such 
        election.
    (d) Direct Billing.--
          (1) In general.--A Tribal Health Program may directly 
        bill for, and receive payment for, health care items 
        and services provided by such Indian Tribe or Tribal 
        organization for which payment is made under title 
        XVIII, XIX, or XXI of the Social Security Act or from 
        any other third party payor.
          (2) Direct reimbursement.--
                  (A) Use of Funds.--Each Tribal Health Program 
                exercising the option described in paragraph 
                (1) with respect to a program under a title of 
                the Social Security Act shall be reimbursed 
                directly by that program for items and services 
                furnished without regard to section 401(c), but 
                all amounts so reimbursed shall be used by the 
                Tribal Health Program for the purpose of making 
                any improvements in Tribal facilities or Tribal 
                Health Programs that may be necessary to 
                achieve or maintain compliance with the 
                conditions and requirements applicable 
                generally to such items and services under the 
                program under such title and to provide 
                additional health care services, improvements 
                in health care facilities and Tribal Health 
                Programs, any health care-related purpose, or 
                otherwise to achieve the objectives provided in 
                section 3 of this Act.
                  (B) Audits.--The amounts paid to an Indian 
                Tribe or Tribal Organization exercising the 
                option described in paragraph (1) with respect 
                to a program under a title of the Social 
                Security Act shall be subject to all auditing 
                requirements applicable to programs 
                administered by an Indian Health Program.
                  (C) Identification of source of payments.--If 
                an Indian Tribe or Tribal Organization receives 
                funding from the Service under the Indian Self-
                Determination and Education Assistance Act or 
                an Urban Indian Organization receives funding 
                from the Service under title V of this Act and 
                receives reimbursements or payments under title 
                XVIII, XIX, or XXI of the Social Security Act, 
                such Indian Tribe or Tribal Organization, or 
                Urban Indian Organization, shall provide to the 
                Service a list of each provider enrollment 
                number (or other identifier) under which it 
                receives such reimbursements or payments.
          (3) Examination and implementation of changes.--The 
        Secretary, acting through the Service and with the 
        assistance of the Administrator of the Centers for 
        Medicare & Medicaid Services, shall examine on an 
        ongoing basis and implement any administrative changes 
        that may be necessary to facilitate direct billing and 
        reimbursement under the program established under this 
        subsection, including any agreements with States that 
        may be necessary to provide for direct billing under a 
        program under a title of the Social Security Act.
          (4) Withdrawal from program.--A Tribal Health Program 
        that bills directly under the program established under 
        this subsection may withdraw from participation in the 
        same mannerand under the same conditions that an Indian 
Tribe or Tribal Organization may retrocede a contracted program to the 
Secretary under the authority of the Indian Self-Determination and 
Education Assistance Act (25 U.S.C. 450 et seq.). All cost accounting 
and billing authority under the program established under this 
subsection shall be returned to the Secretary upon the Secretary's 
acceptance of the withdrawal of participation in this program.
    [(b) Determination of appropriations
    [Any payments received by such facility for services 
provided to Indians eligible for benefits under title XIX of 
the Social Security Act [42 U.S.C.A. Sec. 1396 et seq.] shall 
not be considered in determining appropriations for the 
provision of health care and services to Indians.

[Sec. 1643. Amount and use of funds reimbursed through medicare and 
                    medicaid available to Indian Health Service

    [The Secretary shall submit to the President, for inclusion 
in the report required to be transmitted to the Congress under 
section 1671 of this title, an accounting on the amount and use 
of funds made available to the Service pursuant to this 
subchapter as a result of reimbursements through Titles XVIII 
and XIX of the Social Security Act [42 U.S.C.A. Sec. Sec. 1395 
et seq., 1396 et seq.], as amended.]

Sec. 1644. Grants to and Funding Agreements [contracts] with the 
                    Service, Indian Tribes, T[t]ribal [o]Organizations, 
                    and Urban Indian Organizations

    (a) Indian Tribes and Tribal Organizations.--[Access to 
health services]
    The Secretary, acting through the Service, shall make 
grants to or enter into Funding Agreements [contracts] with 
Indian Tribes and T[t]ribal O[o]rganizations to assist such 
Tribes and Tribal O[o]rganizations in establishing and 
administering programs on or near [Federal Indian] reservations 
and trust areas [and in or near Alaska Native villages] to 
assist individual Indians [to]--
          (1) to enroll for benefits under title XVIII, XIX, or 
        XXI [section 1818 of part A and sections 1836 and 1837 
        of part B of Title XVIII] of the Social Security Act 
        and other health benefits programs [[42 U.S.C.A. 
        Sec. Sec. 1395i-2, 1395o, 1395p]]; and
          (2) to pay [monthly] premiums for coverage for such 
        benefits, which may be based on financial need (as 
        determined by the Indian Tribe or Tribes being served 
        based on a schedule of income levels developed or 
        implemented by such Tribe or Tribes). [due to financial 
        need of such individual; and
          [(3) apply for medical assistance provided pursuant 
        to Title XIX of the Social Security Act [42 U.S.C.A. 
        Sec. 1396 et seq.].]
    (b) [Terms and c]Conditions.--
    The Secretary, acting through the Service, shall place 
conditions as deemed necessary to effect the purpose of this 
section in any [contract or] grant or Funding Agreement which 
the Secretary makes with any Indian Tribe or T[t]ribal 
O[o]rganization pursuant to this section. Such conditions shall 
include [, by are not limited to,] requirements that the Indian 
Tribe or Tribal O[o]rganization successfully undertake [to]--
          (1) to determine the population of Indians eligible 
        for the [to be served that are or could be recipients 
        of] benefits described in subsection (a) [under Titles 
        XVIII and XIX of the Social Security Act [42 U.S.C.A. 
        Sec. Sec. 1395 et seq., 1396 et seq.]];
          (2) to educate [assist individual] Indians with 
        respect to the benefits available under the respective 
        programs [in becoming familiar with and utilizing such 
        benefits];
          (3) to provide transportation for [to] such 
        individual Indians to the appropriate offices for 
        enrollment or applications for such benefits [medical 
        assistance];
          (4) to develop and implement[--]
                  [(A) a schedule of income levels to determine 
                the extent of payments of premiums by such 
                organizations for coverage of needy 
                individuals; and]
                  [(B)] methods of improving the participation 
                of Indians in receiving the benefits provided 
                under titles XVIII, [and] XIX, and XXI of the 
                Social Security Act [[42 U.S.C.A. 
                Sec. Sec. 1395 et seq. And 1396 et seq.]].
    (c) Agreements Relating To Improving Enrollment of Indians 
Under Social Security Act Programs.--[Application for medical 
assistance]
          (1) Agreements With Secretary To Improve Receipt 
andProcessing of Applications.--
                  (A) Authorization.--The Secretary, acting 
                through the Service, may enter into an 
                agreement with an Indian [t]Tribe, [t]Tribal 
                [o]Organization, or [u]Urban Indian 
                [o]Organization which provides for the receipt 
                and processing of applications by Indians for 
                [medical] assistance under titles XIX and XXI 
                of the Social Security Act, [[42 U.S.C.A. 
                Sec. 1396 et seq.]] and benefits under title 
                XVIII of such [the Social Security] Act, by an 
                Indian Health Program or Urban Indian 
                Organization. [[42 U.S.C.A. Sec. 1395 et seq.] 
                at a Service facility or a health care facility 
                administered by such tribe or organization 
                pursuant to a contract under the Indian Self-
                Determination Act [25 U.S.C.A Sec. 450f et 
                seq.].]
                  (B) Reimbursement of costs.--Such agreements 
                may provide for reimbursement of costs of 
                outreach, education regarding eligibility and 
                benefits, and translation when such services 
                are provided. The reimbursement may, as 
                appropriate, be added to the applicable rate 
                per encounter or be provided as a separate fee-
                for-service payment to the Indian Tribe or 
                Tribal Organization.
                  (C) Processing clarified.--In this paragraph, 
                the term `processing' does not include a final 
                determination of eligibility.
          (2) Agreements with states for outreach on or near 
        reservation.--
                  (A) In general.--In order to improve the 
                access of Indians residing on or near a 
                reservation to obtain benefits under title XIX 
                or XXI of the Social Security Act, as a 
                condition of continuing approval of a State 
                plan under such title, the State shall take 
                steps as to provide for enrollment on or near 
                the reservation. Such steps may include 
                outreach efforts such as the outstationing of 
                eligibility workers, entering into agreements 
                with Indian Tribes and Tribal Organizations to 
                provide outreach, education regarding 
                eligibility and benefits, enrollment, and 
                translation services when such services are 
                provided.
                  (B) Construction.--Nothing in subparagraph 
                (A) shall be construed as affecting 
                arrangements entered into between States and 
                Indian Tribes and Tribal Organizations for such 
                Indian Tribes and Tribal Organizations to 
                conduct administrative activities under such 
                titles.
    (d) Facilitating Cooperation.--The Secretary, acting 
through the Centers for Medicare & Medicaid Services, shall 
take such steps as are necessary to facilitate cooperation 
with, and agreements between, States and the Service, Indian 
Tribes, Tribal Organizations, or Urban Indian Organizations.
    (e) Application to Urban Indian Organizations.--
          (1) In general.--The provisions of subsection (a) 
        shall apply with respect to grants and other funding to 
        Urban Indian Organizations with respect to populations 
        served by such organizations in the same manner they 
        apply to grants and Funding Agreements with Indian 
        Tribes and Tribal Organizations with respect to 
        programs on or near reservations.
          (2) Requirements.--The Secretary shall include in the 
        grants or Funding Agreements made or provided under 
        paragraph (1) requirements that are--
                  (A) consistent with the requirements imposed 
                by the Secretary under subsection (b);
                  (B) appropriate to Urban Indian Organizations 
                and Urban Indians; and
                  (C) necessary to effect the purposes of this 
                section.

[Sec. 1645. Direct billing of Medicare, Medicaid, and other third party 
                    payors

    [(a) Establishment of direct billing program
          [(1) In general
          [The Secretary shall establish a program under which 
        Indian tribes, tribal organizations, and Alaska Native 
        health organizations that contract or compact for the 
        operation of a hospital or clinic of the Service under 
        the Indian Self-Determination and Education Assistance 
        Act may elect to directly bill for, and receive payment 
        for, health care services provided by such hospital or 
        clinic for which payment is made under title XVIII of 
        the Social Security Act (42 U.S.C. 1395 et seq.) (In 
        this section referred to as the ``medicare program''), 
        under a State plan for medical assistance approved 
        under title XIX of the Social Security Act (42 U.S.C. 
        1396 et seq.) (In this section referred to as the 
        ``medicaid program''), or from any other third party 
        payor.
          [(2) Application of 100 percent fmap
          [The third sentence of section 1396d(b) of Title 42 
        shall apply for purposes of reimbursement under the 
        medicaid program for health care services directly 
        billed under the program established under this 
        section.
    [(b) Direct reimbursement
          [(1) Use of funds
          [Each hospital or clinic participating in the program 
        described in subsection (a) of this section shall be 
        reimbursed directly under the medicare and medicaid 
        programs for services furnished, without regard to the 
        provisions of section 1880(c) of the Social Security 
        Act (42 U.S.C. 1395qq(c)) and sections 1642(a) and 
        1680c(b)(2)(A) of this title, but all funds so 
        reimbursed shall first be used by the hospital or 
        clinic for the purpose of making any improvements in 
        the hospital or clinic that may be necessary to achieve 
        or maintain compliance with the conditions and 
        requirements applicable generally to facilities of such 
        type under the medicare or medicaid programs. Any funds 
        so reimbursed which are in excess of the amount 
        necessary to achieve or maintain such conditions shall 
        be used--
                  [(A) solely for improving the health 
                resources deficiency level of the Indian tribe; 
                and
                  [(B) in accordance with the regulations of 
                the Service applicable to funds provided by the 
                Service under any contract entered into under 
                the Indian Self-Determination Act (25 U.S.C. 
                450f et seq.).
          [(2) Audits
          [The amounts paid to the hospitals and clinics 
        participating in the program established under this 
        section shall be subject to all auditing requirements 
        applicable to programs administered directly by the 
        Service and to facilities participating in the medicare 
        and medicaid programs.
          [(3) Secretarial oversight
          [The Secretary shall monitor the performance of 
        hospitals and clinics participating in the program 
        established under this section, and shall require such 
        hospitals and clinics to submit reports on the program 
        to the Secretary on an annual basis.
          [(4) No payments from special funds
          [Notwithstanding section 1880(c) of the Social 
        Security Act (42 U.S.C.A. Sec. 1395qq(c)) or section 
        1642(a) of this title, no payment may be made out of 
        the special funds described in such sections for the 
        benefit of any hospital or clinic during the period 
        that the hospital or clinic participates in the program 
        established under this section.
      [(c) Requirements for participation
          [(1) Application
          [Except as provided in paragraph (2)(B), in order to 
        be eligible for participation in the program 
        established under this section, an Indian tribe, tribal 
        organization, or Alaska Native health organization 
        shall submit an application to the Secretary that 
        establishes to the satisfaction of the Secretary that--
                  [(A) the Indian tribe, tribal organization, 
                or Alaska Native health organization contracts 
                or compacts for the operation of a facility of 
                the Service;
                  [(B) the facility is eligible to participate 
                in the medicare or medicaid programs under 
                section 1395qq or 1396j of Title 42;
                  [(C) the facility meets the requirements that 
                apply to programs operated directly by the 
                Service; and
                  [(D) the facility--
                          [(i) is accredited by an accrediting 
                        body as eligible for reimbursement 
                        under the medicare or medicaid 
                        programs; or
                          [(ii) has submitted a plan, which has 
                        been approved by the Secretary, for 
                        achieving such accreditation.
          [(2) Approval
                  [(A) In general
                  [The Secretary shall review and approve a 
                qualified application not later than 90 days 
                after the date that application is submitted to 
                the Secretary unless the Secretary determines 
                that any of the criteria set forth in paragraph 
                (1) are not met.
                  [(B) Grandfather of demonstration program 
                participants
                  [Any participant in the demonstration program 
                authorized under this section as in effect on 
                November 1, 2000,shall be deemed approved for 
participation in the program established under this section and shall 
not be required to submit an application in order to participate in the 
program.
                  [(C) Duration
                  [An approval by the Secretary of a qualified 
                application under subparagraph (A), or a deemed 
                approval of a demonstration program under 
                subparagraph (B), shall continue in effect as 
                long as the approved applicant or the deemed 
                approved demonstration program meets the 
                requirements of this section.
      [(d) Examination and implementation of changes
          [(1) In general
          [The Secretary, acting through the Service, and with 
        the assistance of the Administrator of the Centers for 
        Medicare & Medicaid Services, shall examine on an 
        ongoing basis and implement--
                  [(A) any administrative changes that may be 
                necessary to facilitate direct bill and 
                reimbursement under the program established 
                under this section, including any agreements 
                with States that may be necessary to provide 
                for direct billing under the Medicaid program; 
                and
                  [(B) any changes that may be necessary to 
                enable participants in the program established 
                under this section to provide to the Service 
                medical records information on patients served 
                under the program that is consistent with the 
                medical records information system of the 
                Service.
          [(2) Accounting information
          [The accounting information that a participant in the 
        program established under this section shall be 
        required to report shall be the same as the information 
        required to be reported by participants in the 
        demonstration program authorized under this section as 
        in effect on the day before November 1.2000. The 
        Secretary may from time to time, after consultation 
        with the program participants, change the accounting 
        information submission requirements.
      [(e) Withdrawal from program
      [A participant in the program established under this 
section may withdraw from participation in the same manner and 
under the same conditions that a tribe or tribal organization 
may retrocede a contracted program to the Secretary under 
authority of the Indian Self-Determination Act [25 U.S.C.A. 
Sec. 450f et seq.] . All cost accounting and billing authority 
under the program established under this section shall be 
returned to the Secretary upon the Secretary's acceptance of 
the withdrawal of participation in this program.]

Sec. 403. Reimbursement From Certain Third Parties of Costs of Health 
                    Services

    (a) Right of Recovery.--Except as provided in subsection 
(f), the United States, and Indian Tribe, or Tribal 
Organization shall have the right to recover from an insurance 
company, health maintenance organization, employee benefit 
plan, third-party tortfeasor, or any other responsible or 
liable third party (including a political subdivision or local 
governmental entity of a State) the reasonable charges billed 
(or, if charges are not billed, the operational, 
administrative, and other expenses incurred) by the Secretary, 
an Indian Tribe, or Tribal Organization in providing health 
services, through the Service, an Indian Tribe, or Tribal 
Organization to any individual to the same extent that such 
individual, or any nongovernmental provider of such services, 
would be eligible to receive damages, reimbursement, or 
indemnification for such charges or expenses if--
          (1) such services had been provided by a 
        nongovernmental provider; and
          (2) such individual had been required to pay such 
        charges or expenses and did pay such charges or 
        expenses.
    (b) Limitations on Recoveries From States.--Subsection (a) 
shall provide a right of recovery against any State, only if 
the injury, illness, or disability for which health services 
were provided is covered under--
          (1) workers' compensation laws; or
          (2) a no-fault automobile accident insurance plan or 
        program.
    (c) Nonapplication of Other Laws.--No law of any State, or 
of any political subdivision of a State and no provision of any 
contract, insurance or health maintenance organization policy, 
employee benefit plan, self-insurance plan, managed care plan, 
or other health care plan or program entered into or renewed 
after the date of the enactment of the Indian Health Care 
Amendments of 1988, shall prevent or hinder the right of 
recovery of the United States, an Indian Tribe, or 
TribalOrganization under subsection (a).
    (d) No Effect on Private Rights of Action.--No action taken 
by the United States, an Indian Tribe, or Tribal Organization 
to enforce the right of recovery provided under this section 
shall operate to deny to the injured person the recovery for 
that portion of the person's damage not covered hereunder.
    (e) Enforcement.--
          (1) In general.--The United States, an Indian Tribe, 
        or Tribal Organization may enforce the right of 
        recovery provided under subsection (a) by--
                  (A) intervening or joining in any civil 
                action or proceeding brought--
                          (i) by the individual for whom health 
                        services were provided by the 
                        Secretary, an Indian Tribe, or Tribal 
                        Organization; or
                          (ii) by any representative or heirs 
                        of such individual, or
                  (B) instituting a civil action, including a 
                civil action for injunctive relief and other 
                relief and including, with respect to a 
                political subdivision or local governmental 
                entity of a State, such an action against an 
                official thereof.
          (2) Notice.--All reasonable efforts shall be made to 
        provide notice of action instituted under paragraph 
        (1)(B) to the individual to whom health services were 
        provided, either before or during the pendency of such 
        action.
    (f) Limitation.--Absent specific written authorization by 
the governing body of an Indian Tribe for the period of such 
authorization (which may not be for a period of more than 1 
year and which may be revoked at any time upon written notice 
by the governing body to the Service), the United States shall 
not have a right of recovery under this section if the injury, 
illness, or disability for which health services were provided 
is covered under a self-insurance plan funded by an Indian 
Tribe, Tribal Organization, or Urban Indian Organization. Where 
such authorization is provided, the Service may receive and 
expend such amounts for the provision of additional health 
services consistent with such authorization.
    (g) Costs and Attorneys' Fees.--In any action brought to 
enforce the provisions of this section, a prevailing plaintiff 
shall be awarded its reasonable attorneys' fees and costs of 
litigation.
    (h) Right of Action Against Insurers, HMOs, Employee 
Benefit Plans, Self-Insurance Plans, and Other Health Care 
Plans or Programs.--Where an insurance company, health 
maintenance organization, employee benefit plan, self-insurance 
plan, managed care plan, or other health care plan or program 
fails or refuses to pay the amount due under subsection (a) for 
services provided to an individual who is a beneficiary, 
participant, or insured of such company, organization, plan, or 
program, the United States, Indian Tribe, or Tribal 
Organization shall have a right to assert and pursue all the 
claims and remedies against such company, organization, plan, 
or program and against the fiduciaries of such company, 
organization, plan, or program that the individual could assert 
or pursue under the terms of the contract, program, or plan or 
applicable Federal, State, or Tribal law.
    (i) Nonapplication of Claims Filing Requirements.--An 
insurance company, health maintenance organization, self-
insurance plan, manage care plan, or other health care plan or 
program (under the Social Security Act or otherwise) may not 
deny a claim for benefits submitted by the Service or by an 
Indian Tribe or Tribal Organization based on the format in 
which the claim is submitted if such format complies with the 
format required for submission of claims under title XVIII of 
the Social Security Act, or recognized under section 1175 of 
such Act.
    (j) Application to Urban Indian Organizations.--The 
previous provisions of this section shall apply to Urban Indian 
Organizations with respect to populations served by such 
Organizations in the same manner they apply to Indian Tribes 
and Tribal Organizations with respect to populations served by 
such Indian Tribes and Tribal Organizations.
    (k) Statute of Limitations.--The provisions of section 2415 
of title 28, United States Code, shall apply to all actions 
commenced under this section, and the references therein to the 
United States are deemed to include Indian Tribes, Tribal 
Organizations, and Urban Indian Organizations.
    (l) Savings.--Nothing in this section shall be construed to 
limit any right of recovery available to the United States, an 
Indian Tribe, or Tribal Organization under the provisions of 
any applicable, Federal, State, or Tribal law, including 
medical lien laws and the Federal Medical Care Recovery Act (42 
U.S.C. 2651 et seq.).

Sec. 404. Crediting of Reimbursements

    (a) Use of Amounts.--
          (1) Retention by program.--Except as provided in 
        section 202(g) (relating to the Catastrophic Health 
        Emergency Fund) and section 807 (relating to health 
        services for ineligible persons), all reimbursements 
        received or recovered under any of the programs 
        described in paragraph (2), including under section 
        807, by reason of the provision of health services by 
        the Service, by an Indian Tribe or Tribal Organization, 
        or by an Urban Indian Organization, shall be credited 
        to the Service, such Indian Tribe or Tribal 
        Organization, or such Urban Indian Organization, 
        respectively, and may be used as provided in section 
        401. In the case of such a service provided by or 
        through a Service Unit, such amounts shall be credited 
        to such unit and used for such purposes.
          (2) Programs covered.--The programs referred to in 
        paragraph (1) are the following:
                  (A) Titles XVIII, XIX, and XXI of the Social 
                Security Act.
                  (B) This Act, including section 807.
                  (C) Public Law 87-693.
                  (D) Any other provision of law.
    (b) No Offset of Amounts.--The Service may not offset or 
limit any amount obligated to any Service Unit or entity 
receiving funding from the Service because of the receipt of 
reimbursements under subsection (a).

Sec. 405. Purchasing Health Care Coverage

    (a) In General.--Insofar as amounts are made available 
under law (including a provision of the Social Security Act, 
the Indian Self-Determination and Education Assistance Act, or 
other law, other than under section 402) to Indian Tribes, 
Tribal Organizations, and Urban Indian Organizations for health 
benefits for Service beneficiaries, Indian Tribes, Tribal 
Organizations, and Urban Indian Organizations may use such 
amounts to purchase health benefits coverage for such 
beneficiaries in any manner, including through--
          (1) a tribally owned and operated health care plan;
          (2) a State or locally authorized or licensed health 
        care plan;
          (3) a health insurance provider or managed care 
        organization; or
          (4) a self-insured plan.
The purchase of such coverage by an Indian Tribe, Tribal 
Organization, or Urban Indian Organization may be based on the 
financial needs of such beneficiaries (as determined by the 
Indian Tribe or Tribes being served based on a schedule of 
income levels developed or implemented by such Indian Tribe or 
Tribes).
    (b) Expenses for Self-Insured Plan.--In the case of a self-
insured plan under subsection (a)(4), the amounts may be used 
for expenses of operating the plan, including administration 
and insurance to limit the financial risks to the entity 
offering the plan.
    (c) Construction.--Nothing in this section shall be 
construed as affecting the use of any amounts not referred to 
in subsection (a).

Sec. 406. Sharing Arrangements with Federal Agencies

    (a) Authority.--
          (1) In general.--The Secretary may enter into (or 
        expand) arrangements for the sharing of medical 
        facilities and services between the Service, Indian 
        Tribes, and Tribal Organizations and the Department of 
        Veterans Affairs and the Department of Defense.
          (2) Consultation by secretary required.--The 
        Secretary may not finalize any arrangement between the 
        Service and a Department described in paragraph (1) 
        without first consulting with the Indian Tribes which 
        will be significantly affected by the arrangement.
    (b) Limitations.--The Secretary shall not take any action 
under this section or under subchapter IV of chapter 81 of 
title 38, United States Code, which would impair--
          (1) the priority access of any Indian to health care 
        services provided through the Service and the 
        eligibility of any Indian to receive health services 
        through the Service;
          (2) the quality of health care services provided to 
        any Indian through the Service;
          (3) the priority access of any veteran to health care 
        services provided by the Department of Veterans 
        Affairs;
          (4) the quality of health care services provided by 
        the Department of Veterans Affairs or the Department of 
        Defense; or
          (5) the eligibility of any Indian who is a veteran to 
        receive health services through the Department of 
        Veterans Affairs.
    (c) Reimbursement.--The Service, Indian Tribe, or Tribal 
Organization shall be reimbursed by the Department of Veterans 
Affairs or the Department of Defense (as the case may be) where 
services are provided through the Service, an Indian Tribe, or 
a Tribal Organization to beneficiaries eligible for services 
from either such Department, notwithstanding any other 
provision of law.
    (d) Construction.--Nothing in this section may be construed 
as creating any right of a non-Indian veteran to obtain health 
services from the Service.

Sec. 407. Payor of Last Resort

    Indian Health Programs and health care programs operated by 
Urban Indian Organizations shall be the payor of last resort 
for services provided to persons eligible for services from 
Indian Health Programs and Urban Indian Organizations, 
notwithstanding any Federal, State, or local law to the 
contrary.

Sec. 408. Nondiscrimination in Qualifications for Reimbursement for 
                    Services

    For purposes of determining the eligibility of an entity 
that is operated by the Service, an Indian Tribe, Tribal 
Organization, or Urban Indian Organization to receive payment 
or reimbursement from any federally funded health care program 
for health care services it furnishes to an Indian, any 
requirement that the entity be licensed or recognized under 
State or local law to furnish such services shall be deemed to 
have been met if the entity meets all the applicable standards 
for such licensure, but the entity need not obtain a license. 
In determining whether the entity meets such standards, the 
absence of licensure of any staff member of the entity may not 
be taken into account.

Sec. 409. Consultation

    (a) National Indian Technical Advisory Group (TAG).--
          (1) Establishment and membership.--The Secretary 
        shall establish within the Centers for Medicare & 
        Medicaid Services a National Indian Technical Advisory 
        Group (in this subsection referred to as the `Advisory 
        Group') which shall have no fewer than 14 members 
        including at least 1 member designated by the Indian 
        Tribes and Tribal Organizations in each Service Area, 1 
        Urban Indian Organization representative, and 1 member 
        representing the Service. The Secretary may appoint 
        additional members upon the recommendation of the 
        Advisory Group.
          (2) Duties.--
                  (A) Identification of issues.--The Advisory 
                Group shall assist the Secretary in identifying 
                and addressing issues regarding the health care 
                programs under the Social Security Act 
                (including medicare, medicaid, and SCHIP) that 
                have implications for Indian Health Programs or 
                Urban Indian Organizations. The Advisory Group 
                shall provide advice to the Secretary with 
                respect to those issues and with respect to the 
                need for the Secretary to engage in 
                consultation with Indian Tribes, Tribal 
                Organizations, and Urban Indian Organizations.
                  (B) Construction.--Nothing in subparagraph 
                (A) shall be construed as affecting any 
                requirement under any applicable Executive 
                order for the Secretary to consult with Indian 
                Tribes in cases of health care policies that 
                have implications for Indian Health Programs or 
                Urban Indian Organizations.
          (3) Nonapplication of federal advisory committee 
        act.--The Federal Advisory Committee Act (5 U.S.C. 
        App.) shall not apply to the Advisory Group.
          (4) Meetings.--The Secretary is authorized to convene 
        meetings of the Advisory Group as often as needed to 
        fulfill the responsibilities under this section.
    (b) Solicitation of Medicaid Advice.--
          (1) In general.--As part of its plan for payment 
        under title XIX of the Social Security Act to a State 
        in which the Service operates or funds health care 
        programs or in which 1 or more Indian Health Programs 
        or Urban Indian Organizations provide health care in 
        the State for which medical assistance is available 
        under such title, the State may establish a process 
        under which the State seeks advice on a regular, 
        ongoing basis from designees of such Indian Health 
        Programs and Urban Indian Organizations on matters 
        relating to the application of such title to and having 
        a direct effect on such Indian Health Programs and 
        Urban Indian Organizations.
          (2) Manner of advice.--The process described in 
        paragraph (1) should include solicitation of advice 
        prior to submission of any plan amendments, waiver 
        requests, and proposals for demonstration projects. 
        Such process may include appointment of an advisory 
        committee and of a designee of such Indian Health 
        Programs and Urban Indian Organizations to the medical 
        care advisory committee advising the State on its 
        medicaid plan.
          (3) Payment of expenses.--Expenses in carrying out 
        this subsection shall be treated as reasonable 
        administrative expenses for which reimbursement may be 
        made under section 1903(a) of the Social Security Act.
    (c) Construction.--Nothing in this section shall be 
construed as superseding existing advisory committees, working 
groups, or other advisory procedures established by the 
Secretary or by any State.

Sec. 410. State Children's Health Insurance Program (SCHIP)

    Notwithstanding any other provision of law, insofar as the 
State health plan of a State under title XXI of the Social 
Security Act may provide (whether through its medicaid plan 
under title XIX of such Act or otherwise) child health 
assistance to individuals who are otherwise served by the 
Service or by an Indian Tribe or Tribal Organization, the 
Secretary may enter into an arrangement with the State and with 
the Service or 1 or more Indian Tribes and Tribal Organizations 
in the State under which a portion of the funds otherwise made 
available to the State under such title with respect to such 
individuals is provided to the Service, Indian Tribe, or Tribal 
Organization, respectively, for the purpose of providing such 
assistance to such individuals consistent with the purposes of 
such title.

Sec. 411. Social Security Act Sanctions

    (a) Requests for Waiver of Sanctions.--For purposes of 
applying any authority under a provision of title XI, XVIII, 
XIX, or XXI of the Social Security Act to seek a waiver of a 
sanction imposed against a health care provider insofar as that 
provider provides services to individuals through an Indian 
Health Program, any requirement that a State request such a 
waiver shall be deemed to be met if such Indian Health Program 
requests such a waiver.
    (b) Safe Harbor for Transactions Between and Among Indian 
Health Care Programs.--For purposes of applying section 
1128B(b) of the Social Security Act, the exchange of anything 
of value between or among the following shall not be treated as 
remuneration if the exchange arises from or relates to any of 
the following health programs:
          (1) An exchange between or among the following:
                  (A) Any Indian Health Program.
                  (B) Any Urban Indian Organization.
          (2) An exchange between an Indian Tribe, Tribal 
        Organization, or an Urban Indian Organization and any 
        patient served or eligible for service from an Indian 
        Tribe, Tribal Organization, or Urban Indian 
        Organization, including patients served or eligible for 
        service pursuant to section 807, but only if such 
        exchange--
                  (A) is for the purpose of transporting the 
                patient for the provision of health care items 
                or services;
                  (B) is for the purpose of providing housing 
                to the patient (including a pregnant patient) 
                and immediate family members or an escort 
                incidental to assuring the timely provision of 
                health care items and services to the patient;
                  (C) is for the purpose of paying premiums, 
                copayments, deductibles, or other cost-sharing 
                on behalf of patients; or
                  (D) consists of an item or service of small 
                value that is provided as a reasonable 
                incentive to secure timely and necessary 
                preventive and other items and services.
          (3) Other exchanges involving an Indian Health 
        Program, an Urban Indian Organization, or an Indian 
        Tribe or Tribal Organization that meet such standards 
        as the Secretary of Health and Human Services, in 
        consultation with the Attorney General, determines is 
        appropriate, taking into account the special 
        circumstances of such Indian Health Programs, Urban 
        Indian Organizations, Indian Tribes, and Tribal 
        Organizations and of patients served by Indian Health 
        Programs, Urban Indian Organizations, Indian Tribes, 
        and Tribal Organizations.

Sec. 412. Cost Sharing

    (a) Coinsurance, Copayments, and Deductibles.--
Notwithstanding any other provision of Federal or State law--
          (1) Protection for eligible indians under social 
        security act health programs.--No Indian who is 
        furnished an item orservice for which payment may be 
made under title XIX or XXI of the Social Security Act may be charged a 
deductible, copayment, or coinsurance, if the item or service is 
furnished by, or upon referral made by, the Service, an Indian Tribe, 
Tribal Organization, or Urban Indian Organization.
          (2) Protection for indians.--No Indian who is 
        furnished an item or service by the Service may be 
        charged a deductible, copayment, or coinsurance.
          (3) No Reduction in amount of payment to indian 
        health providers.--The payment or reimbursement due to 
        the Service, Indian Tribe, Tribal Organization, or 
        Urban Indian Organization under title XIX or XXI of the 
        Social Security Act may not be reduced by the amount of 
        the deductible, copayment, or coinsurance that would be 
        due from the Indian but for the operation of this 
        section.
    (b) Exemption From Medicaid and SCHIP Premiums.--
Notwithstanding any other provision of Federal or State law, no 
Indian who is otherwise eligible for services under title XIX 
of the Social Security Act (relating to the medicaid program) 
or title XXI of such Act (relating to the State children's 
health insurance program) may be charged a premium as a 
condition of receiving benefits under the program under the 
respective title.
    (c) Limitation on Medical Child Support Recovery.--
Notwithstanding any other provision of law, a parent (whether 
or not an Indian) of an Indian child shall not be responsible 
for reimbursing a State or the Federal Government under title 
XIX or XXI of the Social Security Act for the cost of medical 
services relating to the child (including childbirth and 
including, where such child is a minor parent, any child of 
such minor parent) under circumstances in which payment would 
have been made under the contract health services program of an 
Indian Health Program but for the child's (or, in the case of 
medical services relating to childbirth, mother's, or 
grandchild's as the case may be) eligibility under title XIX or 
XXI of the Social Security Act.
    (d) Treatment of Certain Property for Medicaid 
Eligibility.--Notwithstanding any other provision of Federal or 
State law, the following property may not be included when 
determining eligibility for services under title XIX of the 
Social Security Act:
          (1) Property, including interests in real property 
        currently or formerly held in trust by the Federal 
        Government which is protected under applicable Federal, 
        State, or Tribal law or custom from recourse and 
        including public domain allotments.
          (2) Property that has unique religious or cultural 
        significance or that supports subsistence or 
        traditional lifestyle according to applicable Tribal 
        law or custom.
    (e) Continuation of Current Law Protections of Certain 
Indian Property From Medicaid Estate Recovery.--Income, 
resources, and property that are exempt from medicaid estate 
recovery under title XIX of the Social Security Act as of April 
1, 2003, under manual instructions issued to carry out section 
1917(b)(3) of such Act because of Federal responsibility for 
Indian Tribes and Alaska Native Villages shall remain so 
exempt. Nothing in this subsection shall be construed as 
preventing the Secretary from providing additional medicaid 
estate recovery exemptions for Indians.

Sec. 413. Treatment Under Medicaid Managed Care.

    (a) Payment for Services Furnished to Indians.--
          (1) In general.--Subject to paragraph (2), in the 
        case of an Indian who is enrolled with a managed care 
        entity under section 1932 of the Social Security Act 
        (or otherwise under a waiver under title XIX of such 
        Act) and who receives services, covered by a managed 
        care entity, from an Indian Health Program or an Urban 
        Indian Organization, either--
                  (A) the entity shall make payment to the 
                Indian Health Program or Urban Indian 
                Organization at a rate established by the 
                entity for such services that is not less than 
                the rate for preferred providers (or at such 
                other rate as may be negotiated between the 
                entity and such Indian Health Program or Urban 
                Indian Organization) and shall not require 
                submittal of a claim by the enrollee as a 
                condition of payment to the Indian Health 
                Program or Urban Indian Organization; or
                  (B) the State shall provide for payment to 
                the Indian Health Program or Urban Indian 
                Organization under its State plan under title 
                XIX of such Act at the rate otherwise 
                applicable and shall provide for an appropriate 
                adjustment of the capitation payment made to 
                the entity to take into account such payment.
          (2) Payment standards.--The payment provisions shall 
        meet the usual medicaid standards for economy, 
        efficiency, and access to quality care.
    (b) Offering of Managed Care.--If--
          (1) a State elects under its State plan under title 
        XIX of the Social Security Act to provide services 
        through medicaid managed care organizations or through 
        primary care case managers under section 1932 or under 
        a waiver under such title; and
          (2) the Indian Health Program or Urban Indian 
        Organization that is funded in whole or in part by the 
        Service, or a consortium thereof, has established a 
        medicaid managed care organization or a primary care 
        case manager that meets quality standards equivalent to 
        those required of such an organization or manager under 
        such section or waiver,
the State shall enter into an agreement under such section with 
the Service, Indian Tribe, Tribal Organization, or Urban Indian 
Organization, or such consortium, to serve as a medicaid 
managed care organization or a primary care case manager, 
respectively with respect to Indians served by such entity. In 
carrying out this subsection, the Secretary and the State may 
waive requirements regarding enrollment, capitalization, and 
such other matters that might otherwise prevent the application 
of the previous sentence.

Sec. 414. Navajo Nation Medicaid Agency Feasibility Study

    (a) Study.--The Secretary shall conduct a study to 
determine the feasibility of treating the Navajo Nation as a 
State for the purposes of title XIX of the Social Security Act, 
to provide services to Indians living within the boundaries of 
the Navajo Nation through an entity established having the same 
authority and performing the same functions as single-State 
medicaid agencies responsible for the administration of the 
State plan under title XIX of the Social Security Act.
    (b) Considerations.--In conducting the study, the Secretary 
shall consider the feasibility of--
          (1) assigning and paying all expenditures for the 
        provision of services and related administration funds, 
        under title XIX of the Social Security Act, to Indians 
        living within the boundaries of the Navajo Nation that 
        are currently paid to or would otherwise be paid to the 
        State of Arizona, New Mexico, or Utah;
          (2) providing assistance to the Navajo Nation in the 
        development and implementation of such entity for the 
        administration, eligibility, payment, and delivery of 
        medical assistance under title XIX of the Social 
        Security Act;
          (3) providing an appropriate level of matching funds 
        for Federal medical assistance with respect to amounts 
        such entity expends for medical assistance for services 
        and related administrative costs; and
          (4) authorizing the Secretary, at the option of the 
        Navajo Nation, to treat the Navajo Nation as a State 
        for the purposes of title XIX of the Social Security 
        Act (relating to the State children's health insurance 
        program) under terms equivalent to those described in 
        paragraphs (2) through (4).
    (c) Report.--Not later then 3 years after the date of 
enactment of the Indian Health Act Improvement Act Amendments 
of 2004, the Secretary shall submit to the Committee on Indian 
Affairs and Committee on Finance of the Senate and the 
Committee on Resources and Committee on Ways and Means of the 
House of Representatives a report that includes--
          (1) the results of the study under this section;
          (2) a summary of any consultation that occurred 
        between the Secretary and the Navajo Nation, other 
        Indian Tribes, the States of Arizona, New Mexico, and 
        Utah, counties which include Navajo Lands, and other 
        interested parties, in conducting this study;
          (3) projected costs or savings associated with 
        establishment of such entity, and any estimated impact 
        on services provided as described in this section in 
        relation to probable costs or savings; and
          (4) legislative actions that would be required to 
        authorize the establishment of such entity if such 
        entity is determined by the Secretary to be feasible.

[Sec. 1646. Authorization for emergency contract health services

    [With respect to an elderly or disabled Indian receiving 
emergency medical care or services from a non-Service provider 
or in a non-Service facility under the authority of this 
chapter, the time limitation (as a condition of payment) for 
notifying the Service of such treatment or admission shall be 
30 days.]

Sec. 1647. Authorization of [a]Appropriations

    There are authorized to be appropriated such sums as may be 
necessary for each fiscal year through fiscal year 2015 [2000] 
to carry out this title [subchapter].

       TITLE V [SUBCHAPTER IV]--HEALTH SERVICES FOR URBAN INDIANS

Sec. 1651. Purpose

    The purpose of this title [subchapter] is to establish and 
maintain programs in [u]Urban [c]Centers to make health 
services more accessible and available to [u]Urban Indians.

Sec. 1652. Contracts [w]With, and [g]Grants to, [u]Urban Indian 
                    [o]Organizations

    Under authority of the Act of November 2, 1921 (25 U.S.C. 
13), (commonly [popularly] known as the `Snyder Act'), the 
Secretary, acting through the Service, shall enter into 
contracts with, or make grants to, [u]Urban Indian 
[o]Organizations to assist such organizations in the 
establishment and administration, within [the u]Urban 
[c]Centers [in which such organizations are situated], of 
programs which meet the requirements set forth in this title 
[subchapter]. Subject to section 506, t[T]he Secretary, acting 
through the Service, shall include such conditions as the 
Secretary considers necessary to effect the purpose of this 
title [subchapter] in any contract into which the Secretary 
enters [into] with, or in any grant the Secretary makes to, any 
U[u]rban Indian O[o]rganization pursuant to this title 
[subchapter].

Sec. 1653. Contracts and G[g]rants for the P[p]rovision of H[h]ealth 
                    C[c]are and R[r]eferral S[s]ervices

    (a) Requirements for Grants and Contracts._
    Under authority of the Act of November 2, 1921 (25 U.S.C. 
13)[, popularly] (commonly known as the `Snyder Act'), the 
Secretary, acting through the Service, shall enter into 
contracts with, or make grants to, [u]Urban Indian 
[o]Organizations for the provision of health care and referral 
services for [u]Urban Indians [residing in the urban centers in 
which such organizations are situated]. Any such contract or 
grant shall include requirements that the [u]Urban Indian 
[o]Organization successfully undertake to--
          (1) estimate the population of [u]Urban Indians 
        residing in the [u]Urban [c]Center or centers that the 
        organization proposes to serve [in which such 
        organization is situated] who are or could be 
        recipients of health care or referral services;
          (2) estimate the current health status of [u]Urban 
        Indians residing in such [u]Urban [c]Center or centers;
          (3) estimate the current health care needs of 
        [u]Urban Indians residing in such [u]Urban [c]Center or 
        centers;
          (4) provide basic health education, including health 
        promotion and disease prevention education, to Urban 
        Indians [identify all public and private health 
        services resources within such urban center which are 
        or may be available to urban Indians];
          (5) make recommendations to the Secretary and 
        Federal, State, local, and other resource agencies on 
        methods of improving health service programs to meet 
        the needs of Urban Indians [determine the use of public 
        and private health services resources by the urban 
        Indians residing in such urban center]; and
          (6) where necessary, provide, or enter into contracts 
        for the provision of, health care services for Urban 
        Indians. [assist such health services resources in 
        providing services to urban Indians;
          [(7) assist urban Indians in becoming familiar with 
        and utilizing such health services resources;
          [(8) provide basic health education, including health 
        promotion and disease prevention education, to urban 
        Indians;
          [(9) establish and implement training programs to 
        accomplish the referral and education tasks set forth 
        in paragraphs (6) through (8) of this subsection;
          [(10) identify gaps between unmet health needs of 
        urban Indians and the resources available to meet such 
        needs;
          [(11) make recommendations to the Secretary and 
        Federal, State, local, and other resource agencies on 
        methods of improving health service programs to meet 
        the needs of urban Indians; and
          [(12) where necessary, provide, or enter into 
        contracts for the provision of, health care services 
        for urban Indians.]
    (b) Criteria.--[for selection of organizations to enter 
into contracts or receive grants]
    The Secretary, acting through the Service, shall by 
regulation adopted pursuant to section 520 prescribe the 
criteria for selecting [u]Urban Indian [o]Organizations to 
enter into contracts or receive grants under this section. Such 
criteria shall, among other factors, include--
          (1) the extent of unmet health care needs of [u]Urban 
        Indians in the [u]Urban [c]Center or centers involved;
          (2) the size of the [u]Urban Indian population in the 
        [u]Urban [c]Center or centers involved;
          [(3) the accessibility to, and utilization of, health 
        care services (other than services provided under this 
        subchapter) by urban Indians in the urban center 
        involved;]
          (3)[(4)] the extent, if any, to which the activities 
        set forth in subsection (a) [of this section] would 
        duplicate any project funded under this title;[--]
                  [(A) any previous or current public or 
                private health services project in an urban 
                center that was or is funded in a manner other 
                than pursuant to this subchapter; or
                  [(B) any project funded under this 
                subchapter;]
          (4)[(5)] the capability of an [u]Urban Indian 
        [o]Organization to perform the activities set forth in 
        subsection (a) [of this section] and to enter into a 
        contract with the Secretary or to meet the requirements 
        for receiving a grant under this section;
          (5)[(6)] the satisfactory performance and successful 
        completion by an [u]Urban Indian [o]Organization of 
        other contracts with the Secretary under this title 
        [subchapter];
          (6)[(7)] the appropriateness and likely effectiveness 
        of conducting the activities set forth in subsection 
        (a) [of this section] in an [u]Urban [c]Center or 
        centers; and
          (7)[(8)] the extent of existing or likely future 
        participation in the activities set forth in subsection 
        (a) [of this section] by appropriate health and health-
        related Federal, State, local, and other agencies.
    (c) Access to Health Promotion and Disease Prevention 
Programs.--[Grants for health promotion and disease prevention 
services]
    The Secretary, acting through the Service, shall facilitate 
access to[,] or provide[,] health promotion and disease 
prevention services for [u]Urban Indians through grants made to 
[u]Urban Indian [o]Organizations administering contracts 
entered into [pursuant to this section] or receiving grants 
under subsection (a) [of this section].
    (d) [Grants for i]Immunization [s]Services.--
          (1) Access or services provided.--The Secretary, 
        acting through the Service, shall facilitate access to, 
        or provide, immunization services for [u]Urban Indians 
        through grants made to [u]Urban Indian [o]Organizations 
        administering contracts entered into [pursuant to this 
        section] or receiving grants under [subsection (a) of] 
        this section.
          (2) Definition.--For purposes of this subsection, the 
        term `immunization services' means services to provide 
        without charge immunizations against vaccine-
        preventable diseases.
          [(2) In making any grant to carry out this 
        subsection, the Secretary shall take into 
        consideration--
                  [(A) the size of the urban Indian population 
                to be served;
                  [(B) the immunization levels of the urban 
                Indian population, particularly the 
                immunization levels of infants, children, and 
                the elderly;
                  [(C) the utilization by the urban Indians of 
                alternative resources from State and local 
                governments for no-cost or low-cost 
                immunization services to the general 
                population; and
                  [(D) the capability of the urban Indian 
                organization to carry out services pursuant to 
                this subsection.
          [(3) For purposes of this subsection, the term 
        ``immunization services'' means services to provide 
        without charge immunizations against vaccine-
        preventable diseases.]
    (e) Behavioral [Grants for provision of mental h]Health 
[s]Services.--
          (1) Access or services provided.--The Secretary, 
        acting through the Service, shall facilitate access to, 
        or provide, behavioral [mental] health services for 
        [u]Urban Indians through grants made to [u]Urban Indian 
        [o]Organizations administering contracts entered into 
        [pursuant to this section] or receiving grants under 
        subsection (a) [of this section].
          (2) Assessment required.--Except as provided by 
        paragraph (3)(A), a [A] grant may not be made under 
        this subsection to an [u]Urban Indian [o]Organization 
        until that organization has prepared, and the Service 
        has approved, an assessment of the following: [mental 
        health needs of the urban Indian populationconcerned, 
the mental health services and other related resources available to 
that population, the barriers to obtaining those services and 
resources, and the needs that are unmet by such services and 
resources.]
                  (A) The behavioral health needs of the Urban 
                Indian population concerned.
                  (B) The behavioral health services and other 
                related resources available to that population.
                  (C) The barriers to obtaining those services 
                and resources.
                  (D) The needs that are unmet by such services 
                and resources.
          (3) Purposes of grants.--Grants may be made under 
        this subsection[--] for the following:
                  (A) [t]To prepare assessments required under 
                paragraph (2)[;].
                  (B) [t]To provide outreach, educational, and 
                referral services to [u]Urban Indians regarding 
                the availability of direct behavioral [mental] 
                health services, to educate [u]Urban Indians 
                about behavioral [mental] health issues and 
                services, and effect coordination with existing 
                behavioral [mental] health providers in order 
                to improve services to [u]Urban Indians[;].
                  (C) [t]To provide outpatient behavioral 
                [mental] health services to [u]Urban Indians, 
                including the identification and assessment of 
                illness, therapeutic treatments, case 
                management, support groups, family treatment, 
                and other treatment.[; and]
                  (D) [t]To develop innovative behavioral 
                [mental] health service delivery models which 
                incorporate Indian cultural support systems and 
                resources.
    (f) [Grants for p]Prevention [and treatment] of [c]Child 
[a]Abuse
          (1) Access or services provided.--The Secretary, 
        acting through the Service, shall facilitate access 
        to[,] or provide[,] services for [u]Urban Indians 
        through grants to [u]Urban Indian [o]Organizations 
        administering contracts entered into [pursuant to this 
        section] or receiving grants under subsection (a) [of 
        this section] to prevent and treat child abuse 
        (including sexual abuse) among [u]Urban Indians.
          (2) Evaluation required.--Except as provided by 
        paragraph (3)(A), a [A] grant may not be made under 
        this subsection to an [u]Urban Indian [o]Organization 
        until that organization has prepared, and the Service 
        has approved, an assessment that documents the 
        prevalence of child abuse in the [u]Urban Indian 
        population concerned and specifies the services and 
        programs (which may not duplicate existing services and 
        programs) for which the grant is requested.
          (3) Purposes of grants.--Grants may be made under 
        this subsection[--] for the following:
                  (A) [t]To prepare assessments required under 
                paragraph (2)[;].
                  (B) [f]For the development of prevention, 
                training, and education programs for [u]Urban 
                Indians [populations], including child 
                education, parent education, provider training 
                on identification and intervention, education 
                on reporting requirements, prevention 
                campaigns, and establishing service networks of 
                all those involved in Indian child 
                protection.[; and]
                  (C) [t]To provide direct outpatient treatment 
                services (including individual treatment, 
                family treatment, group therapy, and support 
                groups) to [u]Urban Indians who are child 
                victims of abuse (including sexual abuse) or 
                adult survivors of child sexual abuse, to the 
                families of such child victims, and to [u]Urban 
                Indian perpetrators of child abuse (including 
                sexual abuse).
          (4) Considerations when making grants.--In making 
        grants to carry out this subsection, the Secretary 
        shall take into consideration--
                  (A) the support for the [u]Urban Indian 
                [o]Organization demonstrated by the child 
                protection authorities in the area, including 
                committees or other services funded under the 
                Indian Child Welfare Act of 1978 (25 U.S.C. 
                1901 et seq.), if any;
                  (B) the capability and expertise demonstrated 
                by the [u]Urban Indian [o]Organization to 
                address the complex problem of child sexual 
                abuse in the community; and
                  (C) the assessment required under paragraph 
                (2).
    (g) Other Grants.--The Secretary, acting through the 
Service, mayenter into a contract with or make grants to an 
Urban Indian Organization that provides or arranges for the provision 
of health care services (through satellite facilities, provider 
networks, or otherwise) to Urban Indians in more than 1 Urban Center.

Sec. 1654. Contracts and [g]Grants for the [d]Determination of [u]Unmet 
                    [h]Health [c]Care [n]Needs

    (a) Grants and Contracts Authorized.--[Authority]
    Under authority of the Act of November 2, 1921 (25 U.S.C. 
13)[, popularly] (commonly known as the `Snyder Act'), the 
Secretary, acting through the Service, may enter into contracts 
with[,] or make grants to[, u]Urban Indian [o]Organizations 
situated in [u]Urban [c]Centers for which contracts have not 
been entered into[,] or grants have not been made[,] under 
section 503 [1653 of this title].
    (b) Purpose.--The purpose of a contract or grant made under 
this section shall be the determination of the matters 
described in subsection (c)[(b)](1) [of this section] in order 
to assist the Secretary in assessing the health status and 
health care needs of [u]Urban Indians in the [u]Urban [c]Center 
involved and determining whether the Secretary should enter 
into a contract or make a grant under section 503[1653 of this 
title] with respect to the [u]Urban Indian [o]Organization 
which the Secretary has entered into a contract with, or made a 
grant to, under this section.
    (c) [(b)] Grant and Contract Requirements.--
    Any contract entered into, or grant made, by the Secretary 
under this section shall include requirements that--
          (1) the [u]Urban Indian [o]Organization successfully 
        undertakes to--
                  (A) document the health care status and unmet 
                health care needs of [u]Urban Indians in the 
                [u]Urban [c]Center involved; and
                  (B) with respect to [u]Urban Indians in the 
                [u]Urban [c]Center involved, determine the 
                matters described in paragraphs [clauses] (2), 
                (3), (4), and (7)[(8)] of section 503(b) 
                [1653(b) of this title]; and
          (2) the [u]Urban Indian [o]Organization complete 
        performance of the contract, or carry out the 
        requirements of the grant, within 1[one] year after the 
        date on which the Secretary and such organization enter 
        into such contract, or within 1[one] year after such 
        organization receives such grant, whichever is 
        applicable.
    (d) [(c)] No Renewals
    The Secretary may not renew any contract entered into[,] or 
grant made[,] under this section.

Sec. 1655. Evaluations; [r]Renewals

    (a) Procedures for Evaluations.--[Contract compliance and 
performance]
    The Secretary, acting through the Service, shall develop 
procedures to evaluate compliance with grant requirements 
[under this subchapter] and compliance with[,] and performance 
of contracts entered into by [u]Urban Indian [o]Organizations 
under this title [subchapter]. Such procedures shall include 
provisions for carrying out the requirements of this section.
    (b) [Annual onsite e]Evaluations
    The Secretary, acting through the Service, shall evaluate 
the compliance [conduct an annual onsite evaluation] of each 
[u]Urban Indian [o]Organization which has entered into a 
contract or received a grant under section 503 with the terms 
of [1653 of this title for purposes of determining the 
compliance of such organization with, and evaluating the 
performance of such organization under, such contract or the 
terms of] such contract or grant. For purposes of this 
evaluation, in determining the capacity of an Urban Indian 
Organization to deliver quality patient care the Secretary 
shall--
          (1) acting through the Service, conduct an annual 
        onsite evaluation of the organization; or
          (2) accept in lieu of such onsite evaluation evidence 
        of the organization's provisional or full accreditation 
        by a private independent entity recognized by the 
        Secretary for purposes of conducting quality reviews of 
        providers participating in the Medicare program under 
        title XVIII of the Social Security Act.
    (c) Noncompliance; [or u]Unsatisfactory [p]Performance.--
    If, as a result of the evaluations conducted under this 
section, the Secretary determines that an [u]Urban 
Indian[o]Organization has not complied with the requirements of a grant 
or complied with or satisfactorily performed a contract under section 
503[1653 of this title], the Secretary shall, prior to renewing such 
contract or grant, attempt to resolve with the [such] organization the 
areas of noncompliance or unsatisfactory performance and modify the 
[such] contract or grant to prevent future occurrences of [such] 
noncompliance or unsatisfactory performance. If the Secretary 
determines that the [such] noncompliance or unsatisfactory performance 
cannot be resolved and prevented in the future, the Secretary shall not 
renew the [such] contract or grant with the [such] organization and is 
authorized to enter into a contract or make a grant under section 503 
[1653 of this title] with another [u]Urban Indian [o]Organization which 
is situated in the same [u]Urban [c]Center as the [u]Urban Indian 
[o]Organization whose contract or grant is not renewed under this 
section.
    (d) Considerations for [Contract and grant r]Renewals
    In determining whether to renew a contract or grant with an 
[u]Urban Indian [o]Organization under section 503 [1653 of this 
title] which has completed performance of a contract or grant 
under section 504 [1654 of this title], the Secretary shall 
review the records of the [u]Urban Indian [o]Organization, the 
reports submitted under section 507 [1657 of this title, and, 
in the case of a renewal of a contract or grant under section 
1653 of this title], and shall consider the results of the 
onsite evaluations or accreditations [conducted] under 
subsection (b) [of this section].

Sec. 1656. Other [c]Contract and [g]Grant [r]Requirements

    (a) Procurement.--[Federal regulations; exceptions]
    Contracts with [u]Urban Indian [o]Organizations entered 
into pursuant to this title [subchapter] shall be in accordance 
with all Federal contracting laws and regulations relating to 
procurement except that[,] in the discretion of the Secretary, 
such contracts may be negotiated without advertising and need 
not conform to the provisions of sections 1304 and 3131 through 
[3131 to] 3133 of [T]title 40, United States Code.
    (b) Payment Under Contracts or Grants._
    Payments under any contracts or grants pursuant to this 
title shall, notwithstanding any term or condition of such 
contract or grant--[subchapter may be made in advance or by way 
of reimbursement and in such installments and on such 
conditions as the Secretary deems necessary to carry out the 
purposes of this subchapter.]
          (1) be made in their entirety by the Secretary to the 
        Urban Indian Organization by no later than the end of 
        the first 30 days of the funding period with respect to 
        which the payments apply, unless the Secretary 
        determines through an evaluation under section 505 that 
        the organization is not capable of administering such 
        payments in their entirety; and
          (2) if any portion thereof is unexpended by the Urban 
        Indian Organization during the funding period with 
        respect to which the payments initially apply, shall be 
        carried forward for expenditure with respect to 
        allowable or reimbursable costs incurred by the 
        organization during 1 or more subsequent funding 
        periods without additional justification or 
        documentation by the organization as a condition of 
        carrying forward the availability for expenditure of 
        such funds.
    (c) Revision or [a]Amendment of Contracts.--
    Notwithstanding any provision of law to the contrary, the 
Secretary may, at the request or consent of an [u]Urban Indian 
[o]Organization, revise or amend any contract entered into by 
the Secretary with such organization under this title 
[subchapter] as necessary to carry out the purposes of this 
title [subchapter].
    [(d) Existing Government facilities
    [In connection with any contract or grant entered into 
pursuant to this subchapter, the Secretary may permit an urban 
Indian organization to utilize, in carrying out such contract 
or grant, existing facilities owned by the Federal Government 
within the Secretary's jurisdiction under such terms and 
conditions as may be agreed upon for the use and maintenance of 
such facilities.]
    (d) Fair and [(e)] Uniform [provision of s]Services and 
[a]Assistance.--
    Contracts with[,] or grants to[, u]Urban Indian 
[o]Organizations and regulations adopted pursuant to this title 
[subchapter] shall include provisions to assure the fair and 
uniform provision to [u]Urban Indians of services and 
assistance under such contracts or grants by such 
organizations.
    [(f) Eligibility for health care or referral services
    [Urban Indians, as defined in section 1603(f) of thistitle, 
shall be eligible for health care or referral services provided 
pursuant to this subchapter.]

Sec. 1657. Reports and [r]Records

    (a) [Quarterly r]Reports.--
    For each fiscal year during which an [u]Urban Indian 
[o]Organization receives or expends funds pursuant to a 
contract entered into[,] or a grant received[,] pursuant to 
this title [subchapter], such Urban Indian O[o]rganization 
shall submit to the Secretary not more frequently than every 6 
months, a [quarterly] report that includes the following: 
[including--]
          (1) [i]In the case of a contract or grant under 
        section 503, recommendations pursuant to section 
        503(a)(5). [1653 of this title, information gathered 
        pursuant to clauses (10) and (11) of this subsection 
        (a) of such section;]
          (2) [i]Information on activities conducted by the 
        organization pursuant to the contract or grant[;].
          (3) [a]An accounting of the amounts and purpose[s] 
        for which Federal funds were expended.[; and]
          (4) A minimum set of data, using uniformly defined 
        elements, that is specified by the Secretary in 
        consultation, consistent with section 514, with Urban 
        Indian Organizations. [such other information as the 
        Secretary may request.]
    (b) Audit [by Secretary and Comptroller General].--
    The reports and records of the [u]Urban Indian 
[o]Organization with respect to a contract or grant under this 
title [subchapter] shall be subject to audit by the Secretary 
and the Comptroller General of the United States.
    (c) Cost of [annual private a]Audits.--
    The Secretary shall allow as a cost of any contract or 
grant entered into or awarded under section 502 or 503 [1653 of 
this title] the cost of an annual independent financial 
[private] audit conducted by--
          (1) a certified public accountant[.]; or
          (2) a certified public accounting firm qualified to 
        conduct Federal compliance audits.
    [(d) Health status, services, and areas of unmet needs; 
child welfare
          [(1) The Secretary, acting through the Service, shall 
        submit a report to the Congress not later than March 
        31, 1992, evaluating--
                  [(A) the health status of urban Indians;
                  [(B) The services provided to Indians through 
                this subchapter;
                  [(C) areas of unmet needs in urban areas 
                served under this subchapter; and
                  [(D) areas of unmet needs in urban areas not 
                served under this subchapter.
          [(2) In preparing the report under paragraph (1), the 
        Secretary shall consult with urban Indian health 
        providers and may contract with a national organization 
        representing urban Indian health concerns to conduct 
        any aspect of the report.
          [(3) The Secretary and the Secretary of the Interior 
        shall--
                  [(A) assess the status of the welfare of 
                urban Indian children, including the volume of 
                child protection cases, the prevalence of child 
                sexual abuse, and the extent of urban Indian 
                coordination with tribal authorities with 
                respect to child sexual abuse; and
                  [(B) submit a report on the assessment 
                required under subparagraph (A), together with 
                recommended legislation to improve Indian child 
                protection in urban Indian populations, to the 
                Congress no later than March 31, 1992.]

Sec. 1658. Limitation on [c]Contract [a]Authority

    The authority of the Secretary to enter into contracts or 
to award grants under this title [subchapter] shall be to the 
extent, and in an amount, provided for in appropriation Acts.

Sec. 1659. Facilities [renovation]

    (a) Grants.--The Secretary, acting through the Service, may 
make grants [funds available] to contractors or grant 
recipients under this title [subchapter] for the lease, 
purchase, renovation, construction, or expansion of [minor 
renovations to] facilities, including leased facilities, in 
order to assist suchcontractors or grant recipients in 
complying with applicable licensure or certification requirements 
[meeting or maintaining the Joint Commission for Accreditation of 
Health Care Organizations (JCAHO) standards].
    (b) Loans.--The Secretary, acting through the Service or 
through the Health Resources and Services Administration, may 
provide to contractors or grant recipients under this title 
loans from the Urban Indian Health Care Facilities Revolving 
Loan Fund described in subsection (c), or guarantees for loans, 
for the construction, renovation, expansion, or purchase of 
health care facilities, subject to the following requirements:
          (1) The principal amount of a loan or loan guarantee 
        may cover 100 percent of the costs (other than 
        staffing) relating to the facility, including planning, 
        design, financing, site land development, construction, 
        rehabilitation, renovation, conversion, medical 
        equipment, furnishings, and capital purchase.
          (2) The total of the principal of loans and loan 
        guarantees, respectively, outstanding at any one time 
        shall not exceed such limitations as may be specified 
        in appropriation Acts.
          (3) The loan or loan guarantee may have a term of the 
        shorter of the estimated useful life of the facility or 
        25 years.
          (4) An Urban Indian Organization may assign, and the 
        Secretary may accept assignment of, the revenue of the 
        Urban Indian Organization as security for a loan or 
        loan guarantee under this subsection.
          (5) The Secretary shall not collect application, 
        processing, or similar fees from Urban Indian 
        Organizations applying for loans or loan guarantees 
        under this subsection.
    (c) Fund.--
          (1) Establishment.--There is established in the 
        Treasury of the United States a fund to be known as the 
        Urban Indian Health Care Facilities Revolving Loan Fund 
        (hereafter in this section referred to as the `URLF'). 
        The URLF shall consist of--
                  (A) such amounts as may be appropriated to 
                the URLF;
                  (B) amounts received from Urban Indian 
                Organizations in repayment of loans made to 
                such organizations under paragraph (2); and
                  (C) interest earned on amounts in the URLF 
                under paragraph (3).
          (2) Use of amount in fund.--Amounts in the URLF may 
        be expended by the Secretary, acting through the 
        Service or the Health Resources and Services 
        Administration, to make loans available to Urban Indian 
        Organizations receiving grants or contracts under this 
        title for the purposes, and subject to the 
        requirements, described in subsection (b). Amounts 
        appropriated to the URLF, amounts received from Urban 
        Indian Organizations in repayment of loans, and 
        interest on amounts in the URLF shall remain available 
        until expended.
          (3) Investment of amounts in fund.--The Secretary of 
        the Treasury shall invest such amounts of the URLF as 
        such Secretary determines are not required to meet 
        current withdrawals from the URLF. Such investments may 
        be made only in interest-bearing obligations of the 
        United States. For such purpose, such obligations may 
        be acquired on original issue at the issue price or by 
        purchase of outstanding obligations at the market 
        price. Any obligation acquired by the URLF may be sold 
        by the Secretary of the Treasury at the market price.
          (4) Initial funds.--There are authorized to be 
        appropriated such sums as may be necessary to initiate 
        the URLF. For each fiscal year after the initial year 
        in which funds are appropriated to the URLF, there is 
        authorized to be appropriated an amount equal to the 
        sum of the amount collected by the URLF during the 
        preceding fiscal year and all accrued interest.

Sec. 1660. Office of Urban Indian Health [Programs Branch]

    [(a) Establishment]
    There is hereby established within the Service an Office [a 
Branch] of Urban Indian Health, [Programs] which shall be 
responsible for--
          (1) carrying out the provisions of this title; 
        [subchapter and for]
          (2) providing central oversight of the programs and 
        services authorized under this title; and [subchapter.]
          (3) providing technical assistance to Urban Indian 
        Organizations.
    [(b) Staff, services, and equipment
    [The Secretary shall appoint such employees to work in the 
branch, including a program director, and shall provide such 
services and equipment, as may be necessary for it to carry out 
its responsibilities. The Secretary shall also analyze the need 
to provide at least one urban health program analyst for each 
area office of the Indian Health Service and shall submit his 
findings to the Congress as a part of the Department's fiscal 
year 1993 budget request.]

Sec. 1660a. Grants for [a]Alcohol and [s]Substance [a]Abuse [r]Related 
                    [s]Services

    (a) Grants Authorized.--
    The Secretary, acting through the Service, may make grants 
for the provision of health-related services in prevention of, 
treatment of, rehabilitation of, or school and community-based 
education regarding [in], alcohol and substance abuse in 
[u]Urban [c]Centers to those [u]Urban Indian [o]Organizations 
with which [whom] the Secretary has entered into a contract 
under this title [subchapter] or under section 201 [1621 of 
this title].
    (b) Goals [of grant].--
    Each grant made pursuant to subsection (a) [of this 
section] shall set forth the goals to be accomplished pursuant 
to the grant. The goals shall be specific to each grant as 
agreed to between the Secretary and the grantee.
    (c) Criteria.--
    The Secretary shall establish criteria for the grants made 
under subsection (a) [of this section], including criteria 
relating to the following:[--]
          (1) The size of the [u]Urban Indian population[;].
          [(2) accessibility to, and utilization of, other 
        health resources available to such population;
          [(3) duplication of existing Service or other Federal 
        grants or contracts;]
          (2)[(4) c]Capability of the organization to 
        adequately perform the activities required under the 
        grant[;].
          (3)[(5) s]Satisfactory performance standards for the 
        organization in meeting the goals set forth in such 
        grant.[, which] The standards shall be negotiated and 
        agreed to between the Secretary and the grantee on a 
        grant-by-grant basis.[; and]
          (4)[(6) i]Identification of need for services.
    (d) Allocation of Grants.--The Secretary shall develop a 
methodology for allocating grants made pursuant to this section 
based on the [such] criteria established pursuant to subsection 
(c).
    (e)[(d)] Grants Subject to Criteria.--[Treatment of funds 
received by urban Indian organizations]
    Any funds received by an [u]Urban Indian [o]Organization 
under this Act [chapter] for substance abuse prevention, 
treatment, and rehabilitation shall be subject to the criteria 
set forth in subsection (c) [of this section].

Sec. 1660b. Treatment of [c]Certain [d]Demonstration [p]Projects.

    [(a)] Notwithstanding any other provision of law, the Tulsa 
Clinic and Oklahoma City Clinic demonstration projects shall--[ 
and the Tulsa Clinic demonstration project shall be treated as 
service units in the allocation of resources and coordination 
of care and shall not be subject to the provisions of the 
Indian Self-Determination Act [25 U.S.C.A. Sec. 450f et seq.] 
for the term of such projects. The Secretary shall provide 
assistance to such projects in the development of resources and 
equipment and facility needs.]
          (1) be permanent programs within the Service's direct 
        care program;
          (2) continue to be treated as Service Units in the 
        allocation of resources and coordination of care; and
          (3) continue to meet the requirements and definitions 
        of an urban Indian organization in this Act, and shall 
        not be subject to the provisions of the Indian Self-
        Determination and Education Assistance Act.
    [(b) The Secretary shall submit to the President, for 
inclusion in the report required to be submitted to the 
Congress under section 1671 of this title for fiscal year 1999, 
a report on the findings and conclusions derived from the 
demonstration projects specified in subsection (a) of this 
section.
    [(c) In addition to the amounts made available under 
section1660d of this title to carry out this section through 
fiscal year 2000, there are authorized to be appropriated such sums as 
may be necessary to carry out this section for each of fiscal years 
2001 and 2002.]

Sec. 1660c. Urban NIAAA [t]Transferred [p]Programs

    (a) Grants and Contracts.--[Duty of Secretary]
    The Secretary, through the Office [shall, within the 
Branch] of Urban Indian Health, shall [Programs of the 
Service,] make grants or enter into contracts with Urban Indian 
Organizations for the administration of [u]Urban Indian alcohol 
programs that were originally established under the National 
Institute on Alcoholism and Alcohol Abuse (hereafter in this 
section referred to as ``NIAAA'') and transferred to the 
Service. Such grants and contracts shall become effective no 
later than September 30, 2007.
    (b) Use of Funds.--[grants]
    Grants provided or contracts entered into under this 
section shall be used to provide support for the continuation 
of alcohol prevention and treatment services for [u]Urban 
Indian populations and such other objectives as are agreed upon 
between the Service and a recipient of a grant or contract 
under this section.
    (c) Eligibility.--[for grants]
    Urban Indian [o]Organizations that operate Indian alcohol 
programs originally funded under the NIAAA and subsequently 
transferred to the Service are eligible for grants or contracts 
under this section.
    [(d) Combination of funds
    [For the purpose of carrying out this section, the 
Secretary may combine NIAAA alcohol funds with other substance 
abuse funds currently administered through the Branch of Urban 
Health Programs of the Service.]
    (d)[(e) Evaluation and r]Report.--[to Congress]
    The Secretary shall evaluate and report to [the] Congress 
on the activities of programs funded under this section not 
less than [at least] every 5 years.

Sec. 514. Consultation with Urban Indian Organizations

    (a) In General.--The Secretary shall ensure that the 
Service consults, to the greatest extent practicable, with 
Urban Indian Organizations.
    (b) Definition of Consultation.--For purposes of subsection 
(a), consultation is the open and free exchange of information 
and opinions which leads to mutual understanding and 
comprehension and which emphasizes trust, respect, and shared 
responsibility.

Sec. 515. Federal Tort Claim Act Coverage

    (a) In General.--With respect to claims resulting from the 
performance of functions during fiscal year 2004 and 
thereafter, or claims asserted after September 30, 2003, but 
resulting from the performance of functions prior to fiscal 
year 2004, under a contract, grant agreement, or any other 
agreement authorized under this title, an Urban Indian 
Organization is deemed hereafter to be part of the Service in 
the Department of Health and Human Services while carrying out 
any such contract or agreement and its employees are deemed 
employees of the Service while acting within the scope of their 
employment in carrying out the contract or agreement. After 
September 30, 2003, any civil action or proceeding involving 
such claims brought hereafter against any Urban Indian 
Organization or any employee of such Urban Indian Organization 
covered by this provision shall be deemed to be an action 
against the United States and will be defended by the Attorney 
General and be afforded the full protection and coverage of the 
Federal Tort Claims Act (28 U.S.C. 1346(b), 2671 et seq.).
    (b) Claims Resulting From Performance of Contract or 
Grant.--Beginning with the fiscal year ending September 30, 
2003, and thereafter, the Secretary shall request through 
annual appropriations funds sufficient to reimburse the 
Treasury for any claims paid in the prior fiscal year pursuant 
to the foregoing provisions.

Sec. 516. Urban Youth Treatment Center Demonstration

    (a) Construction and Operation.--The Secretary, acting 
through the Service, through grant or contract, is authorized 
to fund the construction and operation of at least 2 
residential treatment centers in each State described in 
subsection (b) to demonstrate the provision of alcohol and 
substance abuse treatment services to Urban Indian youth in a 
culturally competent residential setting.
    (b) Definition of State.--A State described in this 
subsectionis a State in which--
          (1) there resides Urban Indian youth with need for 
        alcohol and substance abuse treatment services in a 
        residential setting; and
          (2) there is a significant shortage of culturally 
        competent residential treatment services for Urban 
        Indian youth.

Sec. 517. Use of Federal Property and Supplies

    (a) Authorization for Use.--The Secretary, acting through 
the Service, shall allow an Urban Indian Organization that has 
entered into a contract or received a grant pursuant to this 
title, in carrying out such contract or grant, to use existing 
facilities and all equipment therein or pertaining thereto and 
other real and personal property owned by the Federal 
Government within the Secretary's jurisdiction under such terms 
and conditions as may be agreed upon for their use and 
maintenance.
    (b) Donations.--Subject to subsection (d), the Secretary 
may donate to an Urban Indian Organization that has entered 
into a contract or received a grant pursuant to this title any 
personal or real property determined to be excess to the needs 
of the Service or the General Services Administration for 
purposes of carrying out the contract or grant.
    (c) Acquisition of Property for Donation.--The Secretary 
may acquire excess or surplus government personal or real 
property for donation (subject to subsection (d)), to an Urban 
Indian Organization that has entered into a contract or 
received a grant pursuant to this title if the Secretary 
determines that the property is appropriate for use by the 
Urban Indian Organization for a purpose for which a contract or 
grant is authorized under this title.
    (d) Priority.--In the event that the Secretary receives a 
request for donation of a specific item of personal or real 
property described in subsection (b) or (c) from both an Urban 
Indian Organization and from an Indian Tribe or Tribal 
Organization, the Secretary shall give priority to the request 
for donation of the Indian Tribe or Tribal Organization if the 
Secretary receives the request from the Indian Tribe or Tribal 
Organization before the date the Secretary transfers title to 
the property or, if earlier, the date the Secretary transfers 
the property physically to the Urban Indian Organization.
    (e) Urban Indian Organizations Deemed Executive Agency for 
Certain Purposes.--For purposes of section 501 of title 40, 
United States Code, (relating to Federal sources of supply, 
including lodging providers, airlines, and other transportation 
providers), an Urban Indian Organization that has entered into 
a contract or received a grant pursuant to this title shall be 
deemed an executive agency when carrying out such contract or 
grant, and the employees of the Urban Indian Organization shall 
be eligible to have access to such sources of supply on the 
same basis as employees of an executive agency have such 
access.

Sec. 518. Grants for Diabetes Prevention, Treatment, and Control

    (a) Grants Authorized.--The Secretary may make grants to 
those Urban Indian Organizations that have entered into a 
contract or have received a grant under this title for the 
provision of services for the prevention and treatment of, and 
control of the complications resulting from, diabetes among 
Urban Indians.
    (b) Goals.--Each grant made pursuant to subsection (a) 
shall set forth the goals to be accomplished under the grant. 
The goals shall be specific to each grant as agreed to between 
the Secretary and the grantee.
    (c) Establishment of Criteria.--The Secretary shall 
establish criteria for the grants made under subsection (a) 
relating to--
          (1) the size and location of the Urban Indian 
        population to be served;
          (2) the need for prevention of and treatment of, and 
        control of the complications resulting from, diabetes 
        among the Urban Indian population to be served;
          (3) performance standards for the organization in 
        meeting the goals set forth in such grant that are 
        negotiated and agreed to by the Secretary and the 
        grantee;
          (4) the capability of the organization to adequately 
        perform the activities required under the grant; and
          (5) the willingness of the organization to 
        collaborate with the registry, if any, established by 
        the Secretary under section 204(e) in the Area Office 
        of the Service in which the organization is located.
    (d) Funds Subject to Criteria.--Any funds received by an 
Urban Indian Organization under this Act for the prevention, 
treatment, and control of diabetes among Urban Indians shall be 
subject to the criteria developed by the Secretary under 
subsection (c).

Sec. 519. Community Health Representatives

    The Secretary, acting through the Service, may enter into 
contracts with, and make grants to, Urban Indian Organizations 
for the employment of Indians trained as health service 
providers through the Community Health Representatives Program 
under section 109 in the provision of health care, health 
promotion, and disease prevention services to Urban Indians.

Sec. 520. Regulations

    (a) Requirements for Regulations.--The Secretary may 
promulgate regulations to implement the provisions of this 
title in accordance with the following:
          (1) Proposed regulations to implement this Act shall 
        be published in the Federal Register by the Secretary 
        no later than 9 months after the date of the enactment 
        of this Act and shall have no less than a 4-month 
        comment period.
          (2) The authority to promulgate regulations under 
        this Act shall expire 18 months from the date of the 
        enactment of this Act.
    (b) Effective Date of Title.--The amendments to this title 
made by the Indian Health Care Improvement Act Amendments of 
2004 shall be effective on the date of the enactment of such 
amendments, regardless of whether the Secretary has promulgated 
regulations implementing such amendments have been promulgated.

Sec. 521. Eligibility for Services

    Urban Indians shall be eligible and the ultimate 
beneficiaries for health care or referral services provided 
pursuant to this title.

Sec. 1660d. Authorization of [a]Appropriations

    There are authorized to be appropriated such sums as may be 
necessary for each fiscal year through fiscal year 2015 [2000] 
to carry out this title [subchapter].

          TITLE VI [SUBCHAPTER V]--ORGANIZATIONAL IMPROVEMENTS

Sec. 1661. Establishment of the Indian Health Service as an A[a]gency 
                    of the Public Health Service

    (a) Establishment.--
          (1) In general.--In order to more effectively and 
        efficiently carry out the responsibilities, 
        authorities, and functions of the United States to 
        provide health care services to Indians and Indian 
        [t]Tribes, as are or may be hereafter [on and after 
        November 23, 1988,] provided by Federal statute or 
        treaties, there is established within the Public Health 
        Service of the Department [of Health and Human 
        Services] the Indian Health Service.
          (2) Assistant secretary of indian health.--The 
        [Indian Health] Service shall be administered by an 
        Assistant Secretary of Indian Health [a Director], who 
        shall be appointed by the President, by and with the 
        advice and consent of the Senate. The Assistant 
        Secretary [Director of the Indian Health Service] shall 
        report to the Secretary. [through the Assistant 
        Secretary for Health of the Department of Health and 
        Human Services.] Effective with respect to an 
        individual appointed by the President, by and with the 
        advice and consent of the Senate, after January 1, 
        2005[1993], the term of service of the Assistant 
        Secretary [Director] shall be 4 years. An Assistant 
        Secretary [A Director] may serve more that 1 term.
          (3) Incumbent.--The individual serving in the 
        position of Director of the Indian Health Service on 
        the day before the date of enactment of the Indian 
        Health Care Improvement Act Amendments of 2004 shall 
        serve as Assistant Secretary.
          (4) Advocacy and consultation.--The position of 
        Assistant Secretary is established to, in a manner 
        consistent with the government-to-government 
        relationship between the United States and Indian 
        Tribes--
                  (A) facilitate advocacy for the development 
                of appropriate Indian health policy; and
                  (B) promote consultation on matters relating 
                to Indian health.
    (b) Agency.--[status]
    The [Indian Health] Service shall be an agency within the 
Public Health Service of the Department [of Health and Human 
Services], and shall not be an office, component, or unit of 
any other agency of the Department.
    (c) Duties.--
    The Assistant Secretary [shall carry out through the 
Director] of [the] Indian Health [Service] shall--
          (1) perform all functions that [which] were, on the 
        day before the date of enactment of the Indian Health 
        Care Improvement Act Amendments of 2004, [November 23, 
        1988,] carried out by or under the direction of the 
        individual serving as Director of the Indian Health 
        Service on that [such] day;
          (2) perform all functions of the Secretary relating 
        to the maintenance and operation of hospital and health 
        facilities for Indians and the planning for, and 
        provision and utilization of, health services for 
        Indians;
          (3) administer all health programs under which health 
        care is provided to Indians based upon their status as 
        Indians which are administered by the Secretary, 
        including [(but not limited to)] programs under--
                  (A) this Act [chapter];
                  (B) the Act of November 2, 1921 (25 U.S.C. 
                13);
                  (C) the Act of August 5, 1954 (42 U.S.C. 2001 
                et seq.);
                  (D) the Act of August 16, 1957 (42 U.S.C. 
                2005 et seq.); and
                  (E) the Indian Self-Determination and 
                Education Assistance Act (25 U.S.C. 450[f] et 
                seq.); [and]
          (4) administer all scholarship and loan functions 
        carried out under title [subchapter] I [of this 
        chapter.];
          (5) report directly to the Secretary concerning all 
        policy- and budget-related matters affecting Indian 
        health;
          (6) collaborate with the Assistant Secretary for 
        Health concerning appropriate matters of Indian health 
        that affect the agencies of the Public Health Service;
          (7) advise each Assistant Secretary of the Department 
        concerning matters of Indian health with respect to 
        which that Assistant Secretary has authority and 
        responsibility;
          (8) advise the heads of other agencies and programs 
        of the Department concerning matters of Indian health 
        with respect to which those heads have authority and 
        responsibility;
          (9) coordinate the activities of the Department 
        concerning matters of Indian health; and
          (10) perform such other functions as the Secretary 
        may designate.
    (d) Authority.--[of Secretary]
          (1) In general.--The Secretary, acting through the 
        Assistant Secretary [Director of the Indian Health 
        Service], shall have the authority--
                  (A) except to the extent provided in 
                paragraph (2), to appoint and compensate 
                employees for the Service in accordance with 
                [T]title 5, United States Code;
                  (B) to enter into contracts for the 
                procurement of goods and services to carry out 
                the functions of the Service; and
                  (C) to manage, expend, and obligate all funds 
                appropriated for the Service.
          (2) Personnel actions.--Notwithstanding any other 
        provisions of law, the provisions of section 12[472] of 
        the Act of June 18, 1934 (48 Stat. 986; 25 U.S.C. 472) 
        [this title], shall apply to all personnel actions 
        taken with respect to new positions created within the 
        Service as a result of its establishment under 
        subsection (a) [of this section].
    (e) References.--Any reference to the Director of the 
Indian Health Service in any Federal law, Executive order, 
rule, regulation, or delegation of authority, or in any 
document of or relating to the Director of the Indian Health 
Service, shall be deemed to refer to the Assistant Secretary.

Sec. 1662. Automated [m]Management [i]Information [s]System

    (a) Establishment.--
          (1) In general.--The Secretary shall establish an 
        automated management information system for the 
        Service.
          (2) Requirements of system.--The information system 
        established under paragraph (1) shall include--
                  (A) a financial management system[,];
                  (B) a patient care information system for 
                each area served by the [s]Service[,];
                  (C) a privacy component that protects the 
                privacy ofpatient information held by, or on 
behalf of, the Service[, and];
                  (D) a services-based cost accounting 
                component that provides estimates of the costs 
                associated with the provision of specific 
                medical treatments or services in each [a]Area 
                office of the Service[.];
                  (E) an interface mechanism for patient 
                billing and accounts receivable system; and
                  (F) a training component.
    (b) Provision of Systems to [Indian t]Tribes and 
[o]Organizations.--[; reimbursement]
    [(1)] The Secretary shall provide each Tribal Health 
Program [Indian tribe and tribal organization that provides 
health services under a contract entered into with the Service 
under the Indian Self-Determination Act [25 U.S.C.A. Sec. 450f 
et seq.]] automated management information systems which--
          (1)[(A)] meet the management information needs of 
        such Tribal Health Program [Indian tribe or tribal 
        organization] with respect to the treatment by the 
        Tribal Health Program [Indian tribe or tribal 
        organization] of patients of the Service[,]; and
          (2)[(B)] meet the management information needs of the 
        Service.
          [(2) The Secretary shall reimburse each Indian tribe 
        or tribal organization for the part of the cost of the 
        operation of a system provided under paragraph (1) 
        which is attributable to the treatment by such Indian 
        tribe or tribal organization of patients of the 
        Service.
          [(3) The Secretary shall provide systems under 
        paragraph (1) to Indian tribes and tribal organizations 
        providing health services in California by no later 
        than September 30, 1990.]
    (c) Access to records.--
    Notwithstanding any other provision of law, each patient 
shall have reasonable access to the medical or health records 
of such patient which are held by, or on behalf of, the 
Service.
    (d) Authority To Enhance Information Technology.--The 
Secretary, acting through the Assistant Secretary, shall have 
the authority to enter into contracts, agreements, or joint 
ventures with other Federal agencies, States, private and 
nonprofit organizations, for the purpose of enhancing 
information technology in Indian health programs and 
facilities.

Sec. 603. Authorization of Appropriations

    There is authorized to be appropriated such sums as may be 
necessary for each fiscal year through fiscal year 2015 to 
carry out this title.

 TITLE VII_BEHAVIORAL HEALTH [SUBCHAPTER V-A--SUBSTANCE ABUSE] PROGRAMS

Sec. 701. Behavioral Health Prevention and Treatment Services

    (a) Purposes.--The purposes of this section are as follows:
          (1) To authorize and direct the Secretary, acting 
        through the Service, Indian Tribes, Tribal 
        Organizations, and Urban Indian Organizations, to 
        develop a comprehensive behavior health prevention and 
        treatment program which emphasizes collaboration among 
        alcohol and substance abuse, social services, and 
        mental health programs.
          (2) To provide information, direction, and guidance 
        relating to mental illness and dysfunction and self-
        destructive behavior, including child abuse and family 
        violence, to those Federal, tribal, State, and local 
        agencies responsible for programs in Indian communities 
        in areas of health care, education, social services, 
        child and family welfare, alcohol and substance abuse, 
        law enforcement, and judicial services.
          (3) To assist Indian Tribes to identify services and 
        resources available to address mental illness and 
        dysfunctional and self-destructive behavior.
          (4) To provide authority and opportunities for Indian 
        Tribes and Tribal Organizations to develop, implement, 
        and coordinate with community-based programs which 
        include identification, prevention, education, 
        referral, and treatment services, including through 
        multidisciplinary resource teams.
          (5) To ensure that Indians, as citizens of the United 
        States and of the States in which they reside, have the 
        same access to behavioral health services to which all 
        citizens have access.
          (6) To modify or supplement existing programs and 
        authorities in the areas identified in paragraph (2).
    (b) Plans.--
          (1) Development.--The Secretary, acting through the 
        Service, Indian Tribes, Tribal Organizations, and Urban 
        Indian Organizations, shall encourage Indian Tribes and 
        Tribal Organizations to develop tribal plans, and Urban 
        Indian Organizations to develop local plans, and for 
        all such groups to participate in developing areawide 
        plans for Indian Behavioral Health Services. The plans 
        shall include, to the extent feasible, the following 
        components:
                  (A) An assessment of the scope of alcohol or 
                other substance abuse, mental illness, and 
                dysfunctional and self-destructive behavior, 
                including suicide, child abuse, and family 
                violence, among Indians, including--
                          (i) the number of Indians served who 
                        are directly or indirectly affected by 
                        such illness or behavior; or
                          (ii) an estimate of the financial and 
                        human cost attributable to such illness 
                        or behavior.
                  (B) An assessment of the existing and 
                additional resources necessary for the 
                prevention and treatment of such illness and 
                behavior, including an assessment of the 
                progress toward achieving the availability of 
                the full continuum of care described in 
                subsection (c).
                  (C) An estimate of the additional funding 
                needed by the Service, Indian Tribes, Tribal 
                Organizations, and Urban Indian Organizations 
                to meet their responsibilities under the plans.
          (2) National clearinghouse.--The Secretary, acting 
        through the Service, shall establish a national 
        clearinghouse of plans and reports on the outcomes of 
        such plans developed by Indian Tribes, Tribal 
        Organizations, Urban Indian Organizations, and Service 
        Areas relating to behavioral health. The Secretary 
        shall ensure access to these plans and outcomes by any 
        Indian Tribe, Tribal Organization, Urban Indian 
        Organization, or the Service.
          (3) Technical assistance.--The Secretary shall 
        provide technical assistance to Indian Tribes, Tribal 
        Organizations, and Urban Indian Organizations in 
        preparation of plans under this section and in 
        developing standards of care that may be used and 
        adopted locally.
    (c) Programs.--The Secretary, acting through the Service, 
Indian Tribes, and Tribal Organizations, shall provide, to the 
extent feasible and if funding is available, programs including 
the following:
          (1) Comprehensive care.--A comprehensive continuum of 
        behavioral health care which provides--
                  (A) community-based prevention, intervention, 
                outpatient, and behavioral health aftercare;
                  (B) detoxification (social and medical);
                  (C) acute hospitalization;
                  (D) intensive outpatient/day treatment;
                  (E) residential treatment;
                  (F) transitional living for those needing a 
                temporary, stable living environment that is 
                supportive of treatment and recovery goals;
                  (G) emergency shelter;
                  (H) intensive case management;
                  (I) Traditional Health Care Practices; and
                  (J) diagnostic services.
          (2) Child care.--Behavioral health services for 
        Indians from birth through age 17, including--
                  (A) preschool and school age fetal alcohol 
                disorder services, including assessment and 
                behavioral intervention;
                  (B) mental health and substance abuse 
                services (emotional, organic, alcohol, drug, 
                inhalant, and tobacco);
                  (C) identification and treatment of co-
                occurring disorders and comorbidity;
                  (D) prevention of alcohol, drug, inhalant, 
                and tobacco use;
                  (E) early intervention, treatment, and 
                aftercare;
                  (F) promotion of healthy choices and 
                lifestyle (related to sexually transmitted 
                diseases, domestic violence,sexual abuse, 
suicide, teen pregnancy, obesity, and other risk/safety issues); and
                  (G) identification and treatment of neglect 
                and physical, mental, and sexual abuse.
          (3) Adult care.--Behavioral health services for 
        Indians from age 18 through 55, including--
                  (A) early intervention, treatment, and 
                aftercare;
                  (B) mental health and substance abuse 
                services (emotional, alcohol, drug, inhalant, 
                and tobacco), including gender specific 
                services;
                  (C) identification and treatment of co-
                occurring disorders (dual diagnosis) and 
                comorbidity;
                  (D) promotion of gender specific healthy 
                choices and lifestyle (related to parenting, 
                partners, domestic violence, sexual abuse, 
                suicide, obesity, and other risk-related 
                behavior);
                  (E) treatment services for women at risk of 
                giving birth to a child with a fetal alcohol 
                disorder; and
                  (F) gender specific treatment for sexual 
                assault and domestic violence.
          (4) Family care.--Behavioral health services for 
        families, including--
                  (A) early intervention, treatment, and 
                aftercare for affected families;
                  (B) treatment for sexual assault and domestic 
                violence; and
                  (C) promotion of healthy choices and 
                lifestyle (related to parenting, partners, 
                domestic violence, and other abuse issues).
          (5) Elder care.--Behavioral health services for 
        Indians 56 years of age and older, including--
                  (A) early intervention, treatment, and 
                aftercare;
                  (B) mental health and substance abuse 
                services (emotional, alcohol, drug, inhalant, 
                and tobacco), including gender specific 
                services;
                  (C) identification and treatment of co-
                occurring disorders (dual diagnosis) and 
                comorbidity;
                  (D) promotion of healthy choices and 
                lifestyle (managing conditions related to 
                aging);
                  (E) gender specific treatment for sexual 
                assault, domestic violence, neglect, physical 
                and mental abuse and exploitation; and
                  (F) identification and treatment of dementias 
                regardless of cause.
    (d) Community Behavioral Health Plan.--
          (1) Establishment.--The governing body of any Indian 
        Tribe, Tribal Organization, or Urban Indian 
        Organization may adopt a resolution for the 
        establishment of a community behavioral health plan 
        providing for the identification and coordination of 
        available resources and programs to identify, prevent, 
        or treat substance abuse, mental illness, or 
        dysfunctional and self-destructive behavior, including 
        child abuse and family violence, among its members or 
        its service population. This plan should include 
        behavioral health services, social services, intensive 
        outpatient services, and continuing aftercare.
          (2) Technical assistance.--At the request of an 
        Indian Tribe, Tribal Organization, or Urban Indian 
        Organization, the Bureau of Indian Affairs and the 
        Service shall cooperate with and provide technical 
        assistance to the Indian Tribe, Tribal Organization, or 
        Urban Indian Organization in the development and 
        implementation of such plan.
          (3) Funding.--The Secretary, acting through the 
        Service, may make funding available to Indian Tribes 
        and Tribal Organizations which adopt a resolution 
        pursuant to paragraph (1) to obtain technical 
        assistance for the development of a community 
        behavioral health plan and to provide administrative 
        support in the implementation of such plan.
    (e) Coordination for Availability of Services.--The 
Secretary, acting through the Service, Indian Tribes, Tribal 
Organizations, and Urban Indian Organizations, shall coordinate 
behavioral health planning, to the extent feasible, with other 
Federal agencies and with State agencies, to encourage 
comprehensive behavioral health services for Indians regardless 
of their place of residence.
    (f) Mental Health Care Need Assessment.--Not later than 1 
year after the date of the enactment of the Indian Health Care 
Improvement Act Amendments of 2004, the Secretary, acting 
through the Service, shall make an assessment of the need for 
inpatient mental health care among Indians and the availability 
and cost of inpatient mental health facilities which can meet 
such need. In making such assessment, the Secretary shall 
consider the possible conversion of existing, underused Service 
hospital beds into psychiatric units to meet such need.

Sec. 702. Memoranda of Agreement with the Department of the Interior

[Sec. 1665. Indian Health Service responsibilities]

    (a) Contents.--Not later than 12 months after the date of 
the enactment of the Indian Health Care Improvement Act 
Amendments of 2004, the Secretary, acting through the Service, 
and the Secretary of the Interior shall develop and enter into 
a memoranda of agreement, or review and update any existing 
memoranda of agreement, as required by section 4205 of the 
Indian Alcohol and Substance Abuse Prevention and Treatment Act 
of 1986 (25 U.S.C. 2411) under which the Secretaries address 
the following:
          (1) The scope and nature of mental illness and 
        dysfunctional and self-destructive behavior, including 
        child abuse and family violence, among Indians.
          (2) The existing Federal, tribal, State, local, and 
        private services, resources, and programs available to 
        provide behavioral health services for Indians.
          (3) The unmet need for additional services, 
        resources, and programs necessary to meet the needs 
        identified pursuant to paragraph (1).
          (4)(A) The right of Indians, as citizens of the 
        United States and of the States in which they reside, 
        to have access to behavioral health services to which 
        all citizens have access.
          (B) The right of Indians to participate in, and 
        receive the benefit of, such services.
          (C) The actions necessary to protect the exercise of 
        such right.
          (5) The responsibilities of the Bureau of Indian 
        Affairs and the Service, including mental illness 
        identification, prevention, education, referral, and 
        treatment services (including services through 
        multidisciplinary resource teams), at the central, 
        area, and agency and Service Unit, Service Area, and 
        headquarters levels to address the problems identified 
        in paragraph (1).
          (6) A strategy for the comprehensive coordination of 
        the behavioral health services provided by the Bureau 
        of Indian Affairs and the Service to meet the problems 
        identified pursuant to paragraph (1), including--
                  (A) the coordination of alcohol and substance 
                abuse programs of the Service, the Bureau of 
                Indian Affairs, and Indian Tribes and Tribal 
                Organizations (developed under the Indian 
                Alcohol and Substance Abuse Prevention and 
                Treatment Act of 1986) with behavioral health 
                initiatives pursuant to this Act, particularly 
                with respect to the referral and treatment of 
                dually diagnosed individuals requiring 
                behavioral health and substance abuse 
                treatment; and
                  (B) ensuring that the Bureau of Indian 
                Affairs and Service programs and services 
                (including multidisciplinary resource teams) 
                addressing child abuse and family violence are 
                coordinated with such non-Federal programs and 
                services.
          (7) Directing appropriate officials of the Bureau of 
        Indian Affairs and the Service, particularly at the 
        agency and Service Unit levels, to cooperate fully with 
        tribal requests made pursuant to community behavioral 
        health plans adopted under section 701(c) and section 
        4206 of the Indian Alcohol and Substance Abuse 
        Prevention and Treatment Act of 1986 (25 U.S.C. 2412).
          (8) Providing for an annual review of such agreement 
        by the Secretaries which shall be provided to Congress 
        and Indian Tribes and Tribal Organizations.
    (b) Specific Provisions Required.--The [Memorandum] 
memoranda of [A]agreement updated or entered into pursuant to 
subsection (a) [section 2411 of this title] shall include 
specific provisions pursuant to which the Service shall assume 
responsibility for--
          (1) the determination of the scope of the problem of 
        alcohol and substance abuse among Indians [people], 
        including the number of Indians within the jurisdiction 
        of the Service who are directly or indirectly affected 
        by alcohol and substance abuse and the financial and 
        human cost;
          (2) an assessment of the existing and needed 
        resourcesnecessary for the prevention of alcohol and 
substance abuse and the treatment of Indians affected by alcohol and 
substance abuse; and
          (3) an estimate of the funding necessary to 
        adequately support a program of prevention of alcohol 
        and substance abuse and treatment of Indians affected 
        by alcohol and substance abuse.
    (c) Consultation.--The Secretary, acting through the 
Service, and the Secretary of the Interior shall, in developing 
the memoranda of agreement under subsection (a), consult with 
and solicit the comments from--
          (1) Indian Tribes and Tribal Organizations;
          (2) Indians;
          (3) Urban Indian Organizations and other Indian 
        organizations; and
          (4) behavioral health service providers.
    (d) Publication.--Each memorandum of agreement entered into 
or renewed (and amendments or modifications thereof) under 
subsection (a) shall be published in the Federal Register. At 
the same time as publication in the Federal Register, the 
Secretary shall provide a copy of such memoranda, amendment, or 
modification to each Indian Tribe, Tribal Organization, and 
Urban Indian Organization.

[Sec. 1665a. Indian Health Service program]

Sec. 703. [(a)] Comprehensive Behavioral Health [p]Prevention and 
                    [t]Treatment [p]Program

    (a) Establishment.--
          (1) In general.--The Secretary, acting through the 
        Service, Indian Tribes, and Tribal Organizations, shall 
        provide a program of comprehensive behavioral health, 
        [alcohol and substance abuse] prevention, [and] 
        treatment, and aftercare, including Traditional Health 
        Care Practices, which shall include--
                  (A) prevention, through educational 
                intervention, in Indian communities;
                  (B) acute detoxification, psychiatric 
                hospitalization, residential, and intensive 
                outpatient [and] treatment;
                  (C) community-based rehabilitation and 
                aftercare;
                  (D) community education and involvement, 
                including extensive training of health care, 
                educational, and community-based personnel; 
                [and]
                  (E) specialized residential treatment 
                programs for high-risk populations, including 
                but not limited to pregnant and postpartum 
                [post partum] women and their children[.]; and
                  (F) diagnostic services.
          (2) Target populations.--The target population of 
        such programs shall be members of Indian [t]Tribes. 
        Efforts to train and educate key members of the Indian 
        community shall also target employees of health, 
        education, judicial, law enforcement, legal, and social 
        service programs.
    (b) Contract [h]Health [s]Services
          (1) In general.--The Secretary, acting through the 
        Service, Indian Tribes, and Tribal Organizations, may 
        enter into contracts with public or private providers 
        of behavioral health [alcohol and substance abuse] 
        treatment services for the purpose of [assisting the 
        Service in] carrying out the program required under 
        subsection (a) [of this section].
          (2) Provision of assistance.--In carrying out this 
        subsection, the Secretary shall provide assistance to 
        Indian [t]Tribes and Tribal Organizations to develop 
        criteria for the certification of behavioral health 
        [alcohol and substance abuse] service providers and 
        accreditation of service facilities which meet minimum 
        standards for such services and facilities [as may be 
        determined pursuant to section 2411(a)(3) of this 
        title].

Sec. 704. Mental Health Technician Program

    (a) In General.--Under the authority of the Act of November 
2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'), 
the Secretary shall establish and maintain a mental health 
technician program within the Service which--
          (1) provides for the training of Indians as mental 
        health technicians; and
          (2) employs such technicians in the provision of 
        community-based mental health care that includes 
        identification, prevention, education, referral, and 
        treatment services.
    (b) Paraprofessional Training.--In carrying out subsection 
(a), the Secretary, acting through the Service, Indian Tribes, 
and Tribal Organizations, shall provide high-standard 
paraprofessional training in mental health care necessary to 
provide quality care to the Indian communities to be served. 
Such training shall be based upon a curriculum developed or 
approved by the Secretary which combines education in the 
theory of mental health care with supervised practical 
experience in the provision of such care.
    (c) Supervision and Evaluation of Technicians.--The 
Secretary, acting through the Service, Indian Tribes, and 
Tribal Organizations, shall supervise and evaluate the mental 
health technicians in the training program.
    (d) Traditional Health Care Practices.--The Secretary, 
acting through the Service, shall ensure that the program 
established pursuant to this subsection involves the use and 
promotion of the Traditional Health Care Practices of the 
Indian Tribes to be served.
    [(c) Grants for model program
          [(1) The Secretary, acting through the Service shall 
        make a grant to the Standing Rock Sioux Tribe to 
        develop a community-based demonstration project to 
        reduce drug and alcohol abuse on the Standing Rock 
        Sioux Reservation and to rehabilitate Indian families 
        afflicted by such abuse.
          [(2) Funds shall be used by the Tribe to--
                  [(A) develop and coordinate community-based 
                alcohol and substance abuse prevention and 
                treatment services for Indian families;
                  [(B) develop prevention and intervention 
                models for Indian families;
                  [(C) conduct community education on alcohol 
                and substance abuse; and
                  [(D) coordinate with existing Federal, State, 
                and tribal services on the reservation to 
                develop a comprehensive alcohol and substance 
                abuse program that assists in the 
                rehabilitation of Indian families that have 
                been or are afflicted by alcoholism.
          [(3) The Secretary shall submit to the President for 
        inclusion in the report to be transmitted to the 
        Congress under section 1671 of this title for fiscal 
        year 1995 an evaluation of the demonstration project 
        established under paragraph (1).]

Sec. 705. Licensing Requirement for Mental Health Care Workers

    Subject to the provisions of section 221, any person 
employed as a psychologist, social worker, or marriage and 
family therapist for the purpose of providing mental health 
care services to Indians in a clinical setting under this Act 
or through a Funding Agreement shall be licensed as a clinical 
psychologist, social worker, or marriage and family therapist, 
respectively, or working under the direct supervision of a 
licensed clinical psychologist, social worker, or marriage and 
family therapist, respectively.

Sec. 1665b. Indian [w]Women [t]Treatment [p]Programs

    (a) Funding.--[Grants]
    The Secretary, consistent with section 701, shall [may] 
make grants to Indian [t]Tribes, [and t]Tribal 
[o]Organizations, and Urban Indian Organizations to develop and 
implement a comprehensive behavioral health [alcohol and 
substance abuse] program of prevention, intervention, 
treatment, and relapse prevention services that specifically 
addresses the spiritual, cultural, historical, social, and 
child care needs of Indian women, regardless of age.
    (b) Use of Funds.--[grants]
    Funds [Grants] made available pursuant to this section may 
be used to--
          (1) develop and provide community training, 
        education, and prevention programs for Indian women 
        relating to behavioral health [alcohol and substance 
        abuse] issues, including fetal alcohol disorders 
        [syndrome and fetal alcohol effect];
          (2) identify and provide psychological services, 
        [appropriate] counseling, advocacy, support, and 
        relapse prevention to Indian women and their families; 
        and
          (3) develop prevention and intervention models for 
        Indian women which incorporate [t]Traditional Health 
        Care Practices [healers], cultural values, and 
        community and family involvement.
    (c) Criteria.--[for review and approval of grant 
applications]
    The Secretary, in consultation with Indian Tribes andTribal 
Organizations, shall establish criteria for the review and approval of 
applications and proposals for funding [grants] under this section.
    (d) Earmark of Certain Funds.--Twenty percent of the funds 
appropriated pursuant to this section shall be used to make 
grants to Urban Indian Organizations.
    [(d) Authorization of appropriations
          [(1) There are authorized to be appropriated to carry 
        out this section $10,000,000 for fiscal year 1993 and 
        such sums as are necessary for each of the fiscal years 
        1994, 1995, 1996, 1997, 1998, 1999, and 2000.
          [(2) Twenty percent of the funds appropriated 
        pursuant to this subsection shall be used to make 
        grants to urban Indian organizations funded under 
        subchapter IV of this chapter.]

Sec. 1665c. Indian [Health Service y]Youth [p]Program

    (a) Detoxification and [r]Rehabilitation.--
    The Secretary, acting through the Service, consistent with 
section 701, shall develop and implement a program for acute 
detoxification and treatment for Indian youths, including 
behavioral health services [who are alcohol and substance 
abusers]. The program shall include regional treatment centers 
designed to include detoxification and rehabilitation for both 
sexes on a referral basis and programs developed and 
implemented by Indian Tribes or Tribal Organizations at the 
local level under the Indian Self-Determination and Education 
Assistance Act. [These r]Regional centers shall be integrated 
with the intake and rehabilitation programs based in the 
referring Indian community.
    (b) Alcohol and Substance Abuse Treatment [c]Centers or 
[f]Facilities
          (1) Establishment.--
                  [(1)](A) In general.--The Secretary, acting 
                through the Service, Indian Tribes, and Tribal 
                Organizations, shall construct, renovate, or, 
                as necessary, purchase, and appropriately staff 
                and operate, at least 1[a] youth regional 
                treatment center or treatment network in each 
                area under the jurisdiction of an [a]Area 
                [o]Office.
                  (B) Area office in california.--For the 
                purposes of this subsection, the [area offices 
                of the Service in Tucson and Phoenix, Arizona, 
                shall be considered one area office and the 
                a]Area [o]Office in California shall be 
                considered to be 2 [two a]Area [o]Offices, 
                1[one] office whose jurisdiction shall be 
                considered to encompass the northern area of 
                the State of California, and 1[one] office 
                whose jurisdiction shall be considered to 
                encompass the remainder of the State of 
                California for the purpose of implementing 
                California treatment networks.
          (2) Funding.--For the purpose of staffing and 
        operating such centers or facilities, funding shall be 
        pursuant to the Act of November 2, 1921 (25 U.S.C. 13).
          (3) Location.--A youth treatment center constructed 
        or purchased under this subsection shall be constructed 
        or purchased at a location within the area described in 
        paragraph (1) agreed upon (by appropriate tribal 
        resolution) by a majority of the Indian T[t]ribes to be 
        served by such center.
          (4) Specific provision of funds.--
                  (A) In general.--Notwithstanding any other 
                provision of this title [subchapter], the 
                Secretary may, from amounts authorized to be 
                appropriated for the purposes of carrying out 
                this section, make funds available to--
                          (i) The Tanana Chiefs Conference, 
                        Incorporated, for the purpose of 
                        leasing, constructing, renovating, 
                        operating and maintaining a residential 
                        youth treatment facility in Fairbanks, 
                        Alaska; and
                          (ii) the Southeast Alaska Regional 
                        Health Corporation to staff and operate 
                        a residential youth treatment facility 
                        without regard to the proviso set forth 
                        in section 4[50b](1) of the Indian 
                        Self-Determination and Education 
                        Assistance Act (25 U.S.C. 450b(l)) 
                        [this title].
                  (B) Provision of services to eligible 
                youths.--Until additional residential youth 
                treatment facilities are established in Alaska 
                pursuant to this section, the facilities 
                specified in subparagraph (A) shall make every 
                effort to provide services to all eligible 
                Indian youths residing in Alaska [such State].
    (c) Intermediate Adolescent Behavioral Health Services.--
          (1) In general.--The Secretary, acting through the 
        Service, Indian Tribes, and Tribal Organizations, may 
        provide intermediate behavioral health services, which 
        may incorporate Traditional Health Care Practices, to 
        Indian children andadolescents, including--
                  (A) pretreatment assistance;
                  (B) inpatient, outpatient, and aftercare 
                services;
                  (C) emergency care;
                  (D) suicide prevention and crisis 
                intervention; and
                  (E) prevention and treatment of mental 
                illness and dysfunctional and self-destructive 
                behavior, including child abuse and family 
                violence.
          (2) Use of funds.--Funds provided under this 
        subsection may be used--
                  (A) to construct or renovate an existing 
                health facility to provide intermediate 
                behavioral health services;
                  (B) to hire behavioral health professionals;
                  (C) to staff, operate, and maintain an 
                intermediate mental health facility, group 
                home, sober housing, transitional housing or 
                similar facilities, or youth shelter where 
                intermediate behavioral health services are 
                being provided;
                  (D) to make renovations and hire appropriate 
                staff to convert existing hospital beds into 
                adolescent psychiatric units; and
                  (E) for intensive home-and community-based 
                services.
          (3) Criteria.--The Secretary, acting through the 
        Service, shall, in consultation with Indian Tribes and 
        Tribal Organizations, establish criteria for the review 
        and approval of applications or proposals for funding 
        made available pursuant to this subsection.
    (d)[(c)] Federally [o]Owned [s]Structures.--
          (1) In general.--The Secretary, [acting through the 
        Service, shall,] in consultation with Indian [t]Tribes 
        and Tribal Organizations, shall--
                  (A) identify and use, where appropriate, 
                federally owned structures suitable for [as] 
                local residential or regional behavioral health 
                [alcohol and substance abuse] treatment 
                [centers] for Indian youths; and
                  (B) establish guidelines, in consultation 
                with Indian Tribes and Tribal Organizations, 
                for determining the suitability of any such 
                federally owned structure to be used for [as a] 
                local residential or regional behavioral health 
                [alcohol and substance abuse] treatment 
                [center] for Indian youths.
          (2) Terms and conditions for use of structure.--Any 
        structure described in paragraph (1) may be used under 
        such terms and conditions as may be agreed upon by the 
        Secretary and the agency having responsibility for the 
        structure and any Indian Tribe or Tribal Organization 
        operating the program.
    (e)[(d)] Rehabilitation and [a]Aftercare [s]Services
          (1) In general.--The Secretary, Indian Tribes, or 
        Tribal Organizations, in cooperation with the Secretary 
        of the Interior, shall develop and implement within 
        each Service [service u]Unit, community-based 
        rehabilitation and follow-up services for Indian youths 
        who are having significant behavioral health problems 
        and require [alcohol or substance abusers which are 
        designed to integrate] long-term treatment, community 
        reintegration, and monitoring to [monitor and] support 
        the Indian youths after their return to their home 
        community.
          (2) Administration.--Services under paragraph (1) 
        shall be provided [administered within each service 
        unit] by trained staff within the community who can 
        assist the Indian youths in their continuing 
        development of self-image, positive problem-solving 
        skills, and nonalcohol or substance abusing behaviors. 
        Such staff may [shall] include alcohol and substance 
        abuse counselors, mental health professionals, and 
        other health professionals and paraprofessionals, 
        including community health representatives.
    (f)[(e)] Inclusion of [f]Family in [y]Youth [t]Treatment 
[p]Program
    In providing the treatment and other services to Indian 
youths authorized by this section, the Secretary, acting 
through the Service, Indian Tribes, and Tribal Organizations, 
shall provide for the inclusion of family members of such 
youths in the treatment programs or other services as may be 
appropriate. Not less that 10 percent of the funds appropriated 
for the purposes of carrying out subsection (e)[(d) of this 
section] shall be used for outpatient care of adult family 
members related to the treatment of an Indian youth under that 
subsection.
    (g)[(f)] Multidrug [a]Abuse Program.--[study]
          [(1)] The Secretary, acting through the Service, 
        Indian Tribes, Tribal Organizations, and Urban Indian 
        Organizations, shall provide, consistent with section 
        701, programs and services to prevent and treat 
        [conduct a study to determine the incidence and 
        prevalence of] the abuse of multiple forms of 
        substances [drugs], including, but not limited to, 
        alcohol, drugs, inhalants, and tobacco, among Indian 
        youths residing in Indian communities, on or near 
        [Indian] reservations, and in urban areas and provide 
        appropriate mental health services to address [the 
        interrelationship of such abuse with] the incidence of 
        mental illness among such youths.
          [(2) The Secretary shall submit a report detailing 
        the findings of such study, together with 
        recommendations based on such findings, to the Congress 
        no later than two years after October 29, 1992.]

Sec. 708. Inpatient and Community-Based Mental Health Facilities 
                    Design, Construction, and Staffing

    Not later than 1 year after the date of the enactment of 
the Indian Health Care Improvement Act Amendments of 2004, the 
Secretary, acting through the Service, Indian Tribes, and 
Tribal Organizations, may provide, in each area of the Service, 
not less than 1 inpatient mental health care facility, or the 
equivalent, for Indians with behavioral health problems. For 
the purposes of this subsection, California shall be considered 
to encompass the northern area of the State of California and 1 
office whose jurisdiction shall be considered to encompass the 
remainder of the State of California. The Secretary shall 
consider the possible conversion of existing, underused Service 
hospital beds into psychiatric units to meet such need.

Sec. 1665d. Training and [c]Community [e]Education

    (a) Program.--[Community education]
    The Secretary, in cooperation with the Secretary of the 
Interior, shall develop and implement or provide funding for 
Indian Tribes and Tribal Organizations to develop and 
implement, within each [s]Service [u]Unit or tribal program, a 
program of community education and involvement which shall be 
designed to provide concise and timely information to the 
community leadership of each tribal community. Such program 
shall include education about behavioral health issues [in 
alcohol and substance abuse] to political leaders, [t]Tribal 
judges, law enforcement personnel, members of tribal health and 
education boards, health care providers including traditional 
practitioners, and other critical members of each tribal 
community. Community-based training (oriented toward local 
capacity development) shall also include tribal community 
provider training (designed for adult learners from the 
communities receiving services for prevention, intervention, 
treatment, and aftercare.)
    (b) Instruction.--[Training]
    The Secretary, acting through the Service, shall, either 
directly or through Indian Tribes and Tribal Organizations [by 
contract], provide instruction in the area of behavioral health 
issues [alcohol and substance abuse], including instruction in 
crisis intervention and family relations in the context of 
alcohol and substance abuse, child sexual abuse, youth alcohol 
and substance abuse, and the causes and effects of fetal 
alcohol disorders [syndrome] to appropriate employees of the 
Bureau of Indian Affairs and the Service, and to personnel in 
schools or programs operated under any contract with the Bureau 
of Indian Affairs or the Service, including supervisors of 
emergency shelters and halfway houses described in section 4213 
of the Indian Alcohol and Substance Abuse Prevention and 
Treatment Act of 1986 (25 U.S.C. 2433) [2433 of this title].
    (c) Training [Community-based training m]Models.--
    In carrying out the education and training programs 
required by this section, the Secretary, [acting through the 
Service and] in consultation with Indian T[t]ribes, Tribal 
Organizations, Indian behavioral health experts, and Indian 
alcohol and substance abuse prevention experts, shall develop 
and provide community-based training models. Such models shall 
address--
          (1) the elevated risk of alcohol and behavioral 
        health problems [substance abuse] faced by children of 
        alcoholics;
          (2) the cultural, spiritual, and multigenerational 
        aspects of behavioral health problem [alcohol and 
        substance abuse] prevention and recovery; and
          (3) community-based and multidisciplinary strategies 
        for preventing and treating behavioral health problems 
        [alcohol and substance abuse].

Sec. 710. Behavioral Health Program

    (a) Innovative Programs.--The Secretary, acting through the 
Service, Indian Tribes, and Tribal Organizations, consistent 
with section 701, may plan, develop, implement, and carry 
outprograms to deliver innovative community-based behavioral health 
services to Indians.
    (b) Funding; Criteria.--The Secretary may award such 
funding for a project under subsection (a) to an Indian Tribe 
or Tribal Organization and may consider the following criteria:
          (1) The project will address significant unmet 
        behavioral health needs among Indians.
          (2) The project will serve a significant number of 
        Indians.
          (3) The project has the potential to deliver services 
        in an efficient and effective manner.
          (4) The Indian Tribe or Tribal Organization has the 
        administrative and financial capability to administer 
        the project.
          (5) The project may deliver services in a manner 
        consistent with Traditional Health Care Practices.
          (6) The project is coordinated with, and avoids 
        duplication of, existing services.
    (c) Equitable Treatment.--For purposes of this subsection, 
the Secretary shall, in evaluating applications or proposals 
for funding for projects to be operated under any Funding 
Agreement, use the same criteria that the Secretary uses in 
evaluating any other application or proposal for such funding.

[Sec. 1665e. Gallup alcohol and substance abuse treatment center

    [(a) Grants for residential treatment
    [The Secretary shall make grants to the Navajo Nation for 
the purpose of providing residential treatment for alcohol and 
substance abuse for adult and adolescent members of the Navajo 
Nation and neighboring tribes.
    [(b) Purposes of grants
    [Grants made pursuant to this section shall (to the extent 
appropriations are made available) be used to--
          [(1) provide at least 15 residential beds each year 
        for adult long-term treatment, including beds for 
        specialized services such as polydrug abusers, dual 
        diagnosis, and specialized services for women with 
        fetal alcohol syndrome children;
          [(2) establish clinical assessment teams consisting 
        of a clinical psychologist, a part-time 
        addictionologist, a master's level assessment 
        counselor, and a certified medical records technician 
        which shall be responsible for conducting individual 
        assessments and matching Indian clients with the 
        appropriate available treatment;
          [(3) provide at least 12 beds for an adolescent 
        shelterbed program in the city of Gallup, New Mexico, 
        which shall serve as a satellite facility to the Acoma/
        Canoncito/Laguna Hospital and the adolescent center 
        located in Shiprock, New Mexico, for emergency crisis 
        services, assessment, and family intervention;
          [(4) develop a relapse program for the purposes of 
        identifying sources of job training and job opportunity 
        in the Gallup area and providing vocational training, 
        job placement, and job retention services to recovering 
        substance abusers; and
          [(5) provide continuing education and training of 
        treatment staff in the areas of intensive outpatient 
        services, development of family support systems, and 
        case management in cooperation with regional colleges, 
        community colleges, and universities.
    [(c) Contract for residential treatment
    [The Navajo Nation, in carrying out the purposes of this 
section, shall enter into a contract with an institution in the 
Gallup, New Mexico area which is accredited by the Joint 
Commission of the Accreditation of Health Care Organizations to 
provide comprehensive alcohol and drug treatment as authorized 
in subsection (b) of this section.
    [(d) Authorization of appropriations
    [There are authorized to be appropriated, for each of 
fiscal years 1996 through 2000, such sums as may be necessary 
to carry out subsection (b) of this section.

[Sec. 1665f. Reports

    [(a) Compilation of data
    [The Secretary, with respect to the administration of any 
health program by a service unit, directly or through contract, 
including a contract under the Indian Self-Determination Act 
[25 U.S.C.A. Sec. 450f et seq.], shall require the compilation 
of data relating to the number of cases or incidents in which 
any Service personnel or services were involved and which 
wererelated, either directly or indirectly, to alcohol or substance 
abuse. Such report shall include the type of assistance provided and 
the disposition of these cases.
    [(b) Referral of data
    [The data compiled under subsection (a) of this section 
shall be provided annually to the affected Indian tribe and 
Tribal Coordinating Committee to assist them in developing or 
modifying a Tribal Action Plan under section 2412 of this 
title.
    [(c) Comprehensive report
    [Each service unit director shall be responsible for 
assembling the data compiled under this section and section 
2434 of this title into an annual tribal comprehensive report. 
Such report shall be provided to the affected tribe and to the 
Director of the Service who shall develop and publish a 
biennial national report based on such tribal comprehensive 
reports.]

Sec. 1665g. Fetal [a]Alcohol [d]Disorder [f]Funding.--syndrome and 
                    fetal alcohol effect grants]

    (a) Programs.--[Award; use; review criteria]
          (1) Establishment.--The Secretary, consistent with 
        section 701, acting through the Service, Indian Tribes, 
        and Tribal Organizations, shall [may make grants to 
        Indian tribes and tribal organizations to] establish 
        and operate fetal alcohol disorder [syndrome and fetal 
        alcohol effect] programs as provided in this section 
        for the purposes of meeting the health status 
        objectives specified in section 3[1602(b) of this 
        title].
          (2) Use of funds.--Funding provided [Grants made] 
        pursuant to this section shall be used for the 
        following:[ to--]
                  (A) To develop and provide for Indians 
                community and in[-]school training, education, 
                and prevention programs relating to fetal 
                alcohol disorders. [FAS and FAE;]
                  (B) To identify and provide behavioral health 
                [alcohol and substance abuse] treatment to 
                high-risk Indian women and high-risk women 
                pregnant with an Indian's child.[;]
                  (C) To identify and provide appropriate 
                psychological services, educational and 
                vocational support, counseling, advocacy, and 
                information to fetal alcohol disorder [FAS and 
                FAE] affected Indians [persons] and their 
                families or caretakers[;].
                  (D) To develop and implement counseling and 
                support programs in schools for fetal alcohol 
                disorder [FAS and FAE] affected Indian 
                children[;].
                  (E) To develop prevention and intervention 
                models which incorporate practitioners of 
                T[t]raditional Health Care Practices [healers], 
                cultural and spiritual values, and community 
                involvement[;].
                  (F) To develop, print, and disseminate 
                education and prevention materials on fetal 
                alcohol disorder. [FAS and FAE; and]
                  (G) To develop and implement, through the 
                tribal consultation process, culturally 
                sensitive assessment and diagnostic tools 
                including dysmorphology clinics and 
                multidisciplinary fetal alcohol and disorder 
                clinics for use in [tribal and urban] Indian 
                communities and Urban Centers.
                  (H) To develop early childhood intervention 
                projects from birth on to mitigate the effects 
                of fetal alcohol disorder among Indians.
                  (I) To develop and fund community-based adult 
                fetal alcohol disorder housing and support 
                services for Indians and for women pregnant 
                with an Indian's child.
          (3) Criteria for applications.--The Secretary shall 
        establish criteria for the review and approval of 
        applications for funding [grants] under this section.
    (b) Services.--[Plan; study; national clearinghouse]
    The Secretary, acting through the Service and Indian 
Tribes, Tribal Organizations, and Urban Indian Organizations, 
shall--
          (1) develop and provide services [an annual plan] for 
        the prevention, intervention, treatment, and aftercare 
        for those affected by fetal alcohol disorder [FAS and 
        FAE] in Indian communities; and
          (2) provide supportive services, directly or through 
        an Indian Tribe, Tribal Organization, or Urban Indian 
        Organization, including services to meet [conduct a 
        study, directly or by contract with any organization, 
        entity, or institution of higher education with 
        significant knowledge of FAS and FAE and 
Indiancommunities, of] the special educational, vocational, school-to-
work transition, and independent living needs of adolescent and adult 
Indians with fetal alcohol disorder. [and Alaska Natives with FAS or 
FAE; and
          [(3) establish a national clearinghouse for 
        prevention and educational materials and other 
        information of FAS and FAE effect in Indian and Alaska 
        Native communities and ensure access to clearinghouse 
        materials by any Indian tribe or urban Indian 
        organization.]
    (c) Task [f]Force.--
    The Secretary shall establish a task force to be known as 
the Fetal Alcohol Disorder [FAS/FAE] Task Force to advise the 
Secretary in carrying out subsection (b) [of this section]. 
Such task force shall be composed of representatives from the 
following:
          (1) The National Institute on Drug Abuse.[,]
          (2) T[t]he National Institute on Alcohol and 
        Alcoholism.[,]
          (3) T[t]he Office of Substance Abuse Prevention.[,]
          (4) T[t]he National Institute of Mental Health.[,]
          (5) T[t]he Service.[,]
          (6) T[t]he Office of Minority Health of the 
        Department of Health and Human Services.[,]
          (7) T[t]]he Administration for Native Americans.[,]
          (8) The National Institute of Child Health and Human 
        Development (NICHD).
          (9) The Centers for Disease Control and Prevention.
          (10) T[t]he Bureau of Indian Affairs.[,]
          (11) Indian T[t]ribes.[,]
          (12) T[t]ribal O[o]rganizations.[,]
          (13) U[u]rban Indian Organizations. [communities, 
        and]
          (14) Indian fetal alcohol disorder [FAS/FAE] experts.
    (d) [Cooperative projects;] Applied R[r]esearch 
P[p]rojects.--
    The Secretary, acting through the Substance Abuse and 
Mental Health Services Administration, shall make funding 
available [grants] to Indian T[t]ribes, T[t]ribal 
O[o]rganizations, and Urban Indian Organizations [universities 
working with Indian tribes on cooperative projects, and urban 
Indian organizations] for applied research projects which 
propose to elevate the understanding of methods to prevent, 
intervene, treat, or provide rehabilitation and behavioral 
health aftercare for Indians and U[u]rban Indians affected by 
fetal alcohol disorder [FAS or FAE].
    [(e) Report
          [(1) The Secretary shall submit to the President, for 
        inclusion in each report required to be transmitted to 
        the Congress under section 1671 of this title, a report 
        on the status of FAS and FAE in the Indian population. 
        Such report shall include, in addition to the 
        information required under section 1602(d) of this 
        title with respect to the health status objective 
        specified in section 1602(b)(27) of this title, the 
        following:
                  [(A) The progress of implementing a uniform 
                assessment and diagnostic methodology in 
                Service and tribally based service delivery 
                systems.
                  [(B) The incidence of FAS and FAE babies born 
                for all births by reservation and urban-based 
                sites.
                  [(C) The prevalence of FAS and FAE affected 
                Indian persons in Indian communities, their 
                primary means of support, and recommendations 
                to improve the support system for these 
                individuals and their families or caretakers.
                  [(D) The level of support received from the 
                entities specified in subsection (c) of this 
                section in the area of FAS and FAE.
                  [(E) The number of inpatient and outpatient 
                substance abuse treatment resources which are 
                specifically designed to meet the unique needs 
                of Indian women, and the volume of care 
                provided to Indian women through these means.
                  [(F) Recommendations regarding the 
                prevention, intervention, and appropriate 
                vocational, educational and other support 
                services for FAS and FAE affected individuals 
                in Indian communities.
          [(2) The Secretary may contract the production of 
        this report to a national organization specifically 
        addressing FASand FAE in Indian communities.
    [(f) Authorization of appropriations
          [(1) There are authorized to be appropriated to carry 
        out this section $22,000,000 for fiscal year 1993 and 
        such sums as may be necessary for each of the fiscal 
        years 1994, 1995, 1996, 1997, 1998, 1999, and 2000.]
    (e) Funding for Urban Indian Organizations.--[(2)] Ten 
percent of the funds appropriated pursuant to this section 
shall be used to make grants to U[u]rban Indian 
O[o]rganizations funded under title V [subchapter IV of this 
chapter].

[Sec. 1665h. Pueblo substance abuse treatment project for San Juan 
                    Pueblo, New Mexico

    [The Secretary, acting through the Service, shall continue 
to make grants, through fiscal year 1995, to the 8 Northern 
Indian Pueblos Council, San Juan Pueblo, New Mexico, for the 
purpose of providing substance abuse treatment services to 
Indians in need of such services.

[Sec. 1665i. Thunder Child Treatment Center

    [(a) The Secretary, acting through the Service, shall make 
a grant to the Intertribal Addictions Recovery Organization, 
Inc. (commonly known as the Thunder Child Treatment Center) at 
Sheridan, Wyoming, for the completion of construction of a 
multiple approach substance abuse treatment center which 
specializes in the treatment of alcohol and drug abuse of 
Indians.
    [(b) For the purposes of carrying out subsection (a) of 
this section, there are authorized to be appropriated 
$2,000,000 for fiscal years 1993 and 1994. No funding shall be 
available for staffing or operation of this facility. None of 
the funding appropriated to carry out subsection (a) of this 
section shall be used for administrative purposes.

[Sec. 1665j. Substance abuse counselor education demonstration project

    [(a) Contracts and grants
    [The Secretary, acting through the Service, may enter into 
contracts with, or make grants to, accredited tribally 
controlled community colleges, tribally controlled 
postsecondary vocational institutions, and eligible community 
colleges to establish demonstration projects to develop 
educational curricula for substance abuse counseling.
    [(b) Use of funds
    [Funds provided under this section shall be used only for 
developing and providing educational curricula for substance 
abuse counseling (including paying salaries for instructors). 
Such curricula may be provided through satellite campus 
programs.
    [(c) Effective period of contract or grant; renewal
    [A contract entered into or a grant provided under this 
section shall be for a period of one year. Such contract or 
grant may be renewed for an additional one year period upon the 
approval of the Secretary.
    [(d) Criteria for review and approval of applications
    [Not later than 180 days after October 29, 1992, the 
Secretary, after consultation with Indian tribes and 
administrators of accredited tribally controlled community 
colleges, tribally controlled postsecondary vocational 
institutions, and eligible community colleges, shall develop 
and issue criteria for the review and approval of applications 
for funding (including applications for renewals of funding) 
under this section. Such criteria shall ensure that 
demonstration projects established under this section promote 
the development of the capacity of such entities to education 
substance abuse counselors.
    [(e) Assistance to recipients
    [The Secretary shall provide such technical and other 
assistance as may be necessary to enable grant recipients to 
comply with the provisions of this section.
    [(f) Report
    [The Secretary shall submit to the President, for inclusion 
in the report which is required to be submitted under section 
1671 of this title for fiscal year 1999, a report on the 
findings and conclusions derived from the demonstration 
projects conducted under this section.]

Sec. 712. Child Sexual Abuse and Prevention Treatment Programs

    (a) Establishment.--The Secretary, acting through the 
Service, and the Secretary of the Interior, Indian Tribes, and 
Tribal Organizations shall establish, consistent with section 
701, in every Service Area, programs involving treatment for--
          (1) victims of sexual abuse who are Indian children 
        or children in an Indian household; and
          (2) perpetrators of child sexual abuse who are Indian 
        or members of an Indian household.
    (b) Use of Funds.--Funding provided pursuant to this 
section shall be used for the following:
          (1) To develop and provide community education and 
        prevention programs related to sexual abuse of Indian 
        children or children in an Indian household.
          (2) To identify and provide behavioral health 
        treatment to victims of sexual abuse who are Indian 
        children or children in an Indian household, and to 
        their family members who are affected by sexual abuse.
          (3) To develop prevention and intervention models 
        which incorporate Traditional Health Care Practices, 
        cultural and spiritual values, and community 
        involvement.
          (4) To develop and implement, through the tribal 
        consultation process, culturally sensitive assessment 
        and diagnostic tools for use in Indian communities and 
        Urban Centers.
          (5) To identify and provide behavioral health 
        treatment to Indian perpetrators and perpetrators who 
        are members of an Indian household--
                  (A) making efforts to begin offender and 
                behavioral health treatment while the 
                perpetrator is incarcerated or at the earliest 
                possible date if the perpetrator is not 
                incarcerated; and
                  (B) providing treatment after the perpetrator 
                is released, until it is determined that the 
                perpetrator is not a threat to children.

Sec. 713. Behavioral Health Research

    The Secretary, in consultation with appropriate Federal 
agencies, shall provide funding to Indian Tribes, Tribal 
Organizations, and Urban Indian Organizations or enter into 
contracts with, or make grants to appropriate institutions for, 
the conduct of research on the incidence and prevalence of 
behavioral health problems among Indians served by the Service, 
Indian Tribes, or Tribal Organizations and among Indians in 
urban areas. Research priorities under this section shall 
include--
          (1) the interrelationship and interdependence of 
        behavioral health problems with alcoholism and other 
        substance abuse, suicide, homicides, other injuries, 
        and the incidence of family violence; and
          (2) the development of models of prevention 
        techniques.
The effect of the interrelationships and interdependencies 
referred to in paragraph (1) on children, and the development 
of prevention techniques under paragraph (2) applicable to 
children, shall be emphasized.

Sec. 714. [(g)] Definitions

    For the purposes of this title [section], the following 
definitions shall apply:
          (1) Assessment.--The term `assessment' means the 
        systematic collection, analysis, and dissemination of 
        information on health status, health needs, and health 
        problems. [The term ``educational curriculum'' means 
        one or more of the following:
                  [(A) Classroom education.
                  [(B) Clinical work experience.
                  [(C) Continuing education workshops.]
          (2) Alcohol-related neurodevelopmental disorders or 
        arnd._The term `alcohol-related neurodevelopmental 
        disorders' or `ARND' means a central nervous system or 
        behavioral disorder, following a maternal history of 
        alcohol consumption during pregnancy, that may 
        involve--
                  (A) physical manifestations such as 
                development delay, intellectual deficit, 
                neurologic abnormalities, or failure to thrive 
                as infants; or
                  (B) behavioral manifestations such as 
                irritability, or for older children, 
                hyperactivity, attention deficit, language 
                dysfunction, or perceptual or judgment 
                difficulties.
    The term ``eligible community college'' means an accredited 
community college that--
                          [(i) is located on or near an 
Indianreservation;
                          [(ii) has entered into a cooperative 
                        agreement with the governing body of 
                        such Indian reservation to carry out a 
                        demonstration project under this 
                        section; and
                          [(iii) has a student enrollment of 
                        not less than 10 percent Indian.]
          (3) Behavioral health aftercare.--The term 
        `behavioral health aftercare' includes those activities 
        and resources used to support recovery following 
        inpatient, residential, intensive substance abuse, or 
        mental health outpatient or outpatient treatment. The 
        purpose is to help prevent or deal with relapse by 
        ensuring that by the time a client or patient is 
        discharged from a level of care, such as outpatient 
        treatment, an aftercare plan has been developed with 
        the client. An aftercare plan may use such resources as 
        a community-based therapeutic group, transitional 
        living facilities, a 12-step sponsor, a local 12-step 
        or other related support group, and other community-
        based providers (mental health professionals, 
        traditional health care practitioners, community health 
        aides, community health representatives, mental health 
        technicians, ministers, etc.)
          [(3) The term ``tribally controlled community 
        college'' has the meaning given such term in section 
        1801(a)(4) of this title.]
          (4) Dual diagnosis._The term `dual diagnosis' means 
        coexisting substance abuse and mental illness 
        conditions or diagnosis. Such clients are sometimes 
        referred to as mentally ill chemical abusers (MICAs).
          [(4) The term ``tribally controlled postsecondary 
        vocational institution'' has the meaning given such 
        term in section 2397h(2) of Title 20.]
          (5) Fetal alcohol disorders.--The term `fetal alcohol 
        disorders' means fetal alcohol syndrome, partial fetal 
        alcohol syndrome and alcohol related neurodevelopmental 
        disorder (ARND).
          (6) Fetal alcohol syndrome or fas.--The term `fetal 
        alcohol syndrome' or `FAS' means a syndrome in which, 
        with a history of maternal alcohol consumption during 
        pregnancy, the following criteria are met:
                  (A) Central nervous system involvement such 
                as developmental delay, intellectual deficit, 
                microencephaly, or neurologic abnormalities.
                  (B) Craniofacial abnormalities with at least 
                2 of the following: microophthalmia, short 
                palpebral fissures, poorly developed philtrum, 
                thin upper lip, flat nasal bridge, and short 
                upturned nose.
                  (C) Prenatal or postnatal growth delay.
          (7) Partial fas.--The term `partial FAS' means, with 
        a history of maternal alcohol consumption during 
        pregnancy, having most of the criteria of FAS, though 
        not meeting a minimum of at least 2 of the following: 
        microophthalmia, short palpebral fissures, poorly 
        developed philtrum, thin upper lip, flat nasal bridge, 
        and short upturned nose.
          (8) Rehabilitation. The term `rehabilitation' means 
        to restore the ability or capacity to engage in usual 
        and customary life activities through education and 
        therapy.
          (9) Substance abuse.--The term `substance abuse' 
        includes inhalant abuse.

Sec. 715. [(h)] Authorization of A[a]ppropriations

    There is [are] authorized to be appropriated [for each of 
fiscal years 1996 through 2000,] such sums as may be necessary 
for each fiscal year through fiscal year 2015 to carry out the 
provisions [purposes] of this title [section]. [Such sums shall 
remain available until expended.]

[Sec. 1665k. Gila River alcohol and substance abuse treatment facility

    [(a) Regional center
    [The Secretary, acting through the Service, shall establish 
a regional youth alcohol and substance abuse prevention and 
treatment center in Sacaton, Arizona, on the Gila River Indian 
Reservation. The center shall be established within facilities 
leased, with the consent of the Gila River Indian Community, by 
the Service from such Community.
    [(b) Name of regional center
    [The center established pursuant to this section shall be 
known as the ``Regional Youth Alcohol and Substance Abuse 
Prevention and Treatment Center''.
    [(c) Unit of regional center
    [The Secretary, acting through the Service, shall 
establish, as a unit of the regional center, a youth alcohol 
and substance abuse prevention and treatment facility in 
Fallon, Nevada.

[Sec. 1665l. Alaska Native drug and alcohol abuse demonstration project

    [(a) The Secretary, acting through the Service, shall make 
grants to the Alaska Native Health Board for the conduct of a 
two-part community-based demonstration project to reduce drug 
and alcohol abuse in Alaska Native villages and to rehabilitate 
families afflicted by such abuse. Sixty percent of such grant 
funds shall be used by the Health Board to stimulate 
coordinated community development programs in villages seeking 
to organize to combat alcohol and drug use. Forty percent of 
such grant funds shall be transferred to a qualified nonprofit 
corporation providing alcohol recovery services in the village 
of St. Mary's, Alaska, to enlarge and strengthen a family life 
demonstration program of rehabilitation for families that have 
been or are afflicted by alcoholism.
    [(b) The Secretary shall submit to the President for 
inclusion in the report required to be submitted to the 
Congress under section 1671 of this title for fiscal year 1995 
an evaluation of the demonstration project established under 
subsection (a) of this section.

[Sec. 1665m. Authorization of appropriations

    [Except as provided in sections 1665b, 1665e, 1665g, 1665i, 
and 1665j of this title, there are authorized to be 
appropriated such sums as may be necessary for each fiscal year 
through fiscal year 2000 to carry out the provisions of this 
subchapter.]

               TITLE VIII [SUBCHAPTER VI]--MISCELLANEOUS

Sec. 1671. Reports

    The President shall, at the time the budget is submitted 
under section 1105 of [T]title 31, United States Code, for each 
fiscal year transmit to [the] Congress a report containing the 
following:[--]
          (1) A[a] report on the progress made in meeting the 
        objectives of this Act[chapter], including a review of 
        programs established or assisted pursuant to this 
        Act[chapter] and [an] assessments and recommendations 
        of additional programs or additional assistance 
        necessary to, at a minimum, provide health services to 
        Indians[,] and ensure a health status for Indians, 
        which are at a parity with the health services 
        available to and the health status of[,] the general 
        population, including specific comparisons of 
        appropriations provided and those required for such 
        parity.[;]
          (2) A[a] report on whether, and to what extent, new 
        national health care programs, benefits, initiatives, 
        or financing systems have had an impact on the purposes 
        of this Act[chapter] and any steps that the Secretary 
        may have taken to consult with Indian [t]Tribes, Tribal 
        Organizations, and Urban Indian Organizations to 
        address such impact, including a report on proposed 
        changes in allocation of funding pursuant to section 
        808.[;]
          (3) A[a] report on the use of health services by 
        Indians--
                  (A) on a national and area or other relevant 
                geographical basis;
                  (B) by gender and age;
                  (C) by source of payment and type of service; 
                [and]
                  (D) comparing such rates of use with rates of 
                use among comparable non-Indian populations[.]; 
                and
                  (E) provided under Funding Agreements.
          (4) A report of contractors to the Secretary on 
        Health Care Educational Loan Repayments every 6 months 
        required by section 110.
          (5) A general audit report of the Secretary on the 
        Health Care Educational Loan Repayment Program as 
        required by section 110(n).
          (6) A report of the findings and conclusions of 
        demonstration programs on development of educational 
        curricula for substance abuse counseling as required in 
        section 126(f).
          (7)[(4) a]A separate statement which specifies the 
        amount of funds requested to carry out the provisions 
        of section 201. [1621 of this title;]
          (8) A report of the evaluations of health promotion 
        and disease prevention as required in section 203(c).
          (9) A biennial report to Congress on infectious 
        diseases asrequired by section 212.
          (10) A report on environmental and nuclear health 
        hazards as required by section 215.
          (11) An annual report on the status of all health 
        care facilities needs as required by section 301(c)(2) 
        and 301(d).
          (12) Reports on safe water and sanitary waste 
        disposal facilities as required by section 302(h).
          (13) An annual report on the expenditure of 
        nonservice funds for renovation as required by sections 
        304(b)(2).
          (14) A report identifying the backlog of maintenance 
        and repair required at Service and tribal facilities 
        required by section 313(a).
          (15) A report providing an accounting of 
        reimbursement funds made available to the Secretary 
        under titles XVIII, XIX, and XXI of the Social Security 
        Act.
          (16) A report on any arrangements for the sharing of 
        medical facilities or services between the Service, 
        Indian Tribes, and Tribal Organizations, and the 
        Department of Veterans Affairs and the Department of 
        Defense, as authorized by section 406.
          (17) A report on evaluation and renewal of Urban 
        Indian programs under section 505.
          (18) A report on the evaluation of programs as 
        required by section 513(d).
          (19) A report on alcohol and substance abuse as 
        required by section 701(f).
          [(5) a separate statement of the total amount 
        obligated or expended in the most recently completed 
        fiscal year to achieve each of the objectives described 
        in section 1680d of this title, relating to infant and 
        maternal mortality and fetal alcohol syndrome;
          [(6) the reports required by the sections 1602(d), 
        1616a(n), 1621b(b), 1621h(j), 1631(c), 1632(g), 
        1634(a)(3), 1643, 1665g(e), and 1680g(a), and 1680l(f) 
        of this title;
          [(7) for fiscal year 1995, the report required by 
        sections 1665a(c)(3) and 1665l(b) of this title;
          [(8) for fiscal year 1997, the interim report 
        required by section 1637(h)(1) of this title; and
          [(9) for fiscal year 1999, the reports required by 
        sections 1637(h)(2), 1660b(b), 1665j(f), and 1680k(g) 
        of this title.]

Sec. 1672. Regulations

    (a) Deadlines.--
          (1) Procedures.--Not later than 90 days after the 
        date of the enactment of the Indian Health Care 
        Improvement Act Amendments of 2004, the Secretary shall 
        initiate procedures under subchapter III of chapter 5 
        of title 5, United States Code, to negotiate and 
        promulgate such regulations or amendments thereto that 
        are necessary to carry out titles I, II, III, and VII 
        and section 817. The Secretary may promulgate 
        regulations to carry out sections 105, 115, 117, and 
        titles IV and V, using the procedures required by 
        chapter V of title 5, United States Code (commonly 
        known as the `Administrative Procedure Act'. The 
        Secretary shall issue no regulations to carry out 
        titles VI and VIII, except as necessary to carry out 
        section 817.
          (2) Proposed regulations.--Proposed regulations to 
        implement this Act shall be published in the Federal 
        Register by the Secretary no later than 270 days after 
        the date of the enactment of the Indian Health Care 
        Improvement Act Amendments of 2004 and shall have no 
        less than a 120-day comment period.
          (3) Expiration of authority.--The authority to 
        promulgate regulations under this Act shall expire 18 
        months from the date of the enactment of this Act.
    (b) Committee.--A negotiated rulemaking committee 
established pursuant to section 565 of title 5, United States 
Code, to carry out this section shall have as its members only 
representatives of the Federal Government and representatives 
of Indian Tribes and Tribal Organizations, a majority of whom 
shall be nominated by and be representatives of Indian Tribes, 
Tribal Organizations, and Urban Indian Organizations from each 
Service Area.
    (c) Adaptation of Procedures.--The Secretary shall adapt 
the negotiated rulemaking procedures to the unique context of 
self-governance and the government-to-government relationship 
between the United States and Indian Tribes.
    (d) Lack of Regulations.--The lack of promulgated 
regulations shall not limit the effect of this Act.
    (e) Inconsistent Regulations.--The provisions of this Act 
shall supersede any conflicting provisions of law in effect on 
the day before the date of the enactment of the Indian Health 
Care Improvement Act Amendments of 2004, and the Secretary is 
authorized to repeal any regulation inconsistent with the 
provisions of this Act.
[Prior to any revision of or amendment to rules or regulations 
promulgated pursuant to this chapter, the Secretary shall 
consult with Indian tribes and appropriate national or regional 
Indian organizations and shall publish any proposed revision or 
amendment in the Federal Register not less than sixty days 
prior to the effective date of such revision or amendment in 
order to provide adequate notice to, and receive comments from, 
other interested parties.

[Sec. 1673. Repealed.

[Sec. 1674. Leases with Indian tribes

    [(a) Notwithstanding any other provision of law, the 
Secretary is authorized, in carrying out the purposes of this 
chapter, to enter into leases with Indian tribes for periods 
not in excess of twenty years. Property leased by the Secretary 
from an Indian tribe may be reconstructed or renovated by the 
Secretary pursuant to an agreement with such Indian tribe.
    [(b) The Secretary may enter into leases, contracts, and 
other legal agreements with Indian tribes or tribal 
organizations which hold--
          [(1) title to;
          [(2) a leasehold interest in; or
          [(3) a beneficial interest in (where title is held by 
        the United States in trust for the benefit of a tribe);
[facilities used for the administration and delivery of health 
services by the Service or by programs operated by Indian 
tribes or tribal organizations to compensate such Indian tribes 
or tribal organizations for costs associated with the use of 
such facilities for such purposes. Such costs include rent, 
depreciation based on the useful life of the building, 
principal and interest paid or accrued, operation and 
maintenance expenses, and other expenses determined by 
regulation to be allowable.]

Sec. 803. Plan of Implementation

    Not later than 8 months after the date of the enactment of 
the Indian Health Care Improvement Act Amendments of 2004, the 
Secretary in consultation with Indian Tribes, Tribal 
Organizations, and Urban Indian Organizations, shall submit to 
Congress a plan explaining the manner and schedule (including a 
schedule of appropriation requests), by title and section, by 
which the Secretary will implement the provisions of this Act.

Sec. 1675. Availability of F[f]unds

    The funds appropriated pursuant to this Act [chapter] shall 
remain available until expended.

Sec. 1676. Limitation on U[u]se of F[f]unds A[a]ppropriated to the 
                    Indian Health Service

    Any limitation on the use of funds contained in an Act 
providing appropriations for the Department [of Health and 
Human Services] for a period with respect to the performance of 
abortions shall apply for that period with respect to the 
performance of abortions using funds contained in an Act 
providing appropriations for the [Indian Health] Service.

[Sec. 1677. Nuclear resource development health hazards

    [(a) Study
    [The Secretary and the Service shall conduct, in 
conjunction with other appropriate Federal agencies and in 
consultation with concerned Indian tribes and organizations, a 
study of the health hazards to Indian miners and Indians on or 
near Indian reservations and in Indian communities as a result 
of nuclear resource development. Such study shall include--
          [(1) an evaluation of the nature and extent of 
        nuclear resource development related health problems 
        currently exhibited among Indians and the causes of 
        such health problems;
          [(2) an analysis of the potential effect of ongoing 
        and future nuclear resource development on or near 
        Indian reservations and communities;
          [(3) an evaluation of the types and nature of 
        activities, practices, and conditions causing or 
        affecting such health problems, including uranium 
        mining and milling, uranium mine tailing deposits, 
        nuclear power plant operation and construction, and 
        nuclear waste disposal;
          [(4) a summary of any findings and recommendations 
        provided in Federal and State studies, reports, 
        investigations, andinspections during the five years 
prior to December 17, 1980, that directly or indirectly relate to the 
activities, practices, and conditions affecting the health or safety of 
such Indians; and
          [(5) the efforts that have been made by Federal and 
        State agencies and mining and milling companies to 
        effectively carry out an education program for such 
        Indians regarding the health and safety hazards of such 
        nuclear resource development.
    [(b) Health care plan; development
    [Upon completion of such study the Secretary and the 
Service shall take into account the results of such study and 
develop a health care plan to address the health problems 
studied under subsection (a) of this section. The plan shall 
include--
          [(1) methods for diagnosing and treating Indians 
        currently exhibiting such health problems;
          [(2) preventive care for Indians who may be exposed 
        to such health hazards, including the monitoring of the 
        health of individuals who have or may have been exposed 
        to excessive amounts of radiation, or affected by other 
        nuclear development activities that have had or could 
        have a serious impact upon the health of such 
        individuals; and
          [(3) a program of education for Indians who, by 
        reason of their work or geographic proximity to such 
        nuclear development activities, may experience health 
        problems.
    [(c) Reports to Congress
    [The Secretary and the Service shall submit to Congress the 
study prepared under subsection (a) of this section no later 
than the date eighteen months after December 17, 1980. The 
health care plan prepared under subsection (b) of this section 
shall be submitted in a report no later than the date one year 
after the date that the study prepared under subsection (a) of 
this section is submitted to Congress. Such report shall 
include recommended activities for the implementation of the 
plan, as well as an evaluation of any activities previously 
undertaken by the Service to address such health problems.
    [(d) Intergovernmental Task Force; establishment and 
functions
          [(1) There is established an Intergovernmental Task 
        Force to be composed of the following individuals (or 
        their designees): the Secretary of Energy, the 
        Administrator of the Environmental Protection Agency, 
        the Director of the United States Bureau of Mines, the 
        Assistant Secretary for Occupational Safety and Health, 
        and the Secretary of the Interior.
          [(2) The Task Force shall identify existing and 
        potential operations related to nuclear resource 
        development that affect or may affect the health of 
        Indians on or near an Indian reservation or in an 
        Indian community and enter into activities to correct 
        existing health hazards and insure that current and 
        future health problems resulting from nuclear resource 
        development activities are minimized or reduced.
          [(3) The Secretary shall be Chairman of the Task 
        Force. The Task Force shall meet at least twice each 
        year. Each member of the Task Force shall furnish 
        necessary assistance to the Task Force.
    [(e) Medical care
    [In the case of any Indian who--
          [(1) as a result of employment in or near a uranium 
        mine or mill, suffers from a work related illness or 
        condition;
          [(2) is eligible to receive diagnosis and treatment 
        services from a Service facility; and
          [(3) by reason of such Indian's employment, is 
        entitled to medical care at the expense of such mine or 
        mill operator;
[the Service shall, at the request of such Indian, render 
appropriate medical care to such Indian for such illness or 
condition and may recover the costs of any medical care so 
rendered to which such Indian is entitled at the expense of 
such operator from such operator. Nothing in this subsection 
shall affect the rights of such Indian to recover damages other 
than such costs paid to the Service from the employer for such 
illness or condition.

[Sec. 1678. Arizona as a contract health service delivery area

    [(a) Designation
    [For the fiscal years beginning with the fiscal year ending 
September 30, 1982, and ending with the fiscal year ending 
September 30, 2000, the State of Arizona shall be designated as 
a contract health service delivery area by the Service for the 
purpose of providing contract health care services to members 
of federally recognized Indian tribes of Arizona.
    [(b) Curtailment of health services prohibited
    [The Service shall not curtail any health care services 
provided to Indians residing on Federal reservations in the 
State of Arizona if such curtailment is due to the provision of 
contract services in such State pursuant to the designation of 
such State as a contract health service delivery area pursuant 
to subsection (a) of this section.]

Sec. 1679. Eligibility of California Indians

    (a) In General._[Report to Congress]
    The following California Indians shall be eligible for 
health services provided by the Service:
          [(1) In order to provide the Congress with sufficient 
        data to determine which Indians in the State of 
        California should be eligible for health services 
        provided by the Service, the Secretary shall, by no 
        later than the date that is 3 years after November 23, 
        1988, prepare and submit to the Congress a report which 
        sets forth--
                  [(A) a determination by the Secretary of the 
                number of Indians described in subsection 
                (b)(2) of this section, and the number of 
                Indians described in subsection (b)(3) of this 
                section, who are not members of an Indian tribe 
                recognized by the Federal Government,
                  [(B) the geographic location of such Indians,
                  [(C) the Indian tribes of which such Indians 
                are members,
                  [(D) an assessment of the current health 
                status, and health care needs, of such Indians, 
                and
                  [(E) an assessment of the actual availability 
                and accessibility of alternative resources for 
                the health care of such Indians that such 
                Indians would have to rely on if the Service 
                did not provide for the health care of such 
                Indians.
          [(2) The report required under paragraph (1) shall be 
        prepared by the Secretary--
                  [(A) in consultation with the Secretary of 
                the Interior, and
                  [(B) with the assistance of the tribal health 
                programs providing services to the Indians 
                described in paragraph (2) or (3) of subsection 
                (b) of this section who are not members of any 
                Indian tribe recognized by the Federal 
                Government.
    [(b) Eligible Indians
    [Until such time as any subsequent law may otherwise 
provide, the following California Indians shall be eligible for 
health services provided by the Service:]
          (1) Any member of a federally recognized Indian 
        T[t]ribe.
          (2) Any descendant of an Indian who was residing in 
        California on June 1, 1852, [but only] if such 
        descendant--
                  [(A) is living in California,]
                  (A)[(B)] is a member of the Indian community 
                served by a local program of the Service[,]; 
                and
                  (B)[(C)] is regarded as an Indian by the 
                community in which such descendant lives.
          (3) Any Indian who holds trust interests in public 
        domain, national forest, or [Indian] reservation 
        allotments in California.
          (4) Any Indian in California who is listed on the 
        plans for distribution of the assets of [California] 
        rancherias and reservations located within the State of 
        California under the Act of August 18, 1958 (72 Stat. 
        619), and any descendant of such an Indian.
    (b)[(c)] Clarification.--[Scope of eligibility]
    Nothing in this section may be construed as expanding the 
eligibility of California Indians for health services provided 
by the Service beyond the scope of eligibility for such health 
services that applied on May 1, 1986.

[Sec. 1680. California as a contract health service delivery area

    [The State of California, excluding the counties of 
Alameda, Contra Costa, Los Angeles, Marin, Orange, Sacramento, 
San Francisco, San Mateo, Santa Clara, Kern, Merced, Monterey, 
Napa, San Benito, San Joaquin, San Luis Obispo, Sant Cruz, 
Solano, Stanislaus, and Ventura shall be designated as a 
contract health service delivery area by the Service for the 
purpose of providing contract health services to Indians in 
such State.

[Sec. 1680a. Contract health facilities

    [The Service shall provide funds for health care programs 
and facilities operated by tribes and tribal organizations 
under contracts with the Service entered into under the Indian 
Self-Determination Act [25 U.S.C.A Sec. 450f et seq.]--
          [(1) for the maintenance and repair of clinics owned 
        or leased by such tribes or tribal organizations,
          [(2) for employee training,
          [(3) for cost-of-living increases for employees, and
          [(4) for any other expenses relating to the provision 
        of health services,
[on the same basis as such funds are provided to programs and 
facilities operated directly by the Service.

[Sec. 1680b. National Health Service Corps

    [The Secretary of Health and Human Services shall not--
          [(1) remove a member of the National Health Service 
        Corps from a health facility operated by the Indian 
        Health Service or by a tribe or tribal organization 
        under contract with the Indian Health Service under the 
        Indian Self-Determination Act [25 U.S.C.A. Sec. 450f et 
        seq.], or
          [(2) withdraw funding used to support such member,
[unless the Secretary, acting through the Service, has ensured 
that the Indians receiving services from such member will 
experience no reduction in services.]

Sec. 1680c. Health S[s]ervices for I[i]neligible P[p]ersons

    (a) Children._Individuals not otherwise eligible
          [(1)] Any individual who--
          (1)[(A)] has not attained 19 years of age[,];
          (2)[(B)] is the natural or adopted child, step[-
        ]child, foster[-]child, legal ward, or orphan of an 
        eligible Indian[,]; and
          (3)[(C)] is not otherwise eligible for the health 
        services provided by the Service, shall be eligible for 
        all health services provided by the Service on the same 
        basis and subject to the same rules that apply to 
        eligible Indians until such individual attains 19 years 
        of age. The existing and potential health needs of all 
        such individuals shall be taken into consideration by 
        the Service in determining the need for, or the 
        allocation of, the health resources of the Service. If 
        such an individual has been determined to be legally 
        incompetent prior to attaining 19 years of age, such 
        individual shall remain eligible for such services 
        until 1[one] year after the date of a determination of 
        competency [such disability has been removed].
    (b) Spouses.--[(2)] Any spouse of an eligible Indian who is 
not an Indian, or who is of Indian descent but not otherwise 
eligible for the health services provided by the Service, shall 
be eligible for such health services if all of such spouses or 
spouses who are married to members of the Indian Tribe(s) being 
served are made eligible, as a class, by an appropriate 
resolution of the governing body of the Indian tribe or Tribal 
Organization providing such services [of the eligible Indian]. 
The health needs of persons made eligible under this paragraph 
shall not be taken into consideration by the Service in 
determining the need for, or allocation of, its health 
resources.
    (c)[(b)] Provision of Services to Other Individuals.--
[Health facilities providing health service]
          (1)[(A)] In general.--The Secretary is authorized to 
        provide health services under this subsection through 
        health programs [facilities] operated directly by the 
        Service to individuals who reside within the [service 
        area of a s]Service [u]Unit and who are not otherwise 
        eligible for such health services [under any other 
        subsection of this section or under any other provision 
        of law] if--
                  (A)[(i)] the Indian T[t]ribes [(or, in the 
                case of a multi-tribal service are, all the 
                Indian tribes)] served by such [s]Service 
                [u]Unit request[s] such provision of health 
                services to such individuals[,]; and
                  (B)[(ii)] the Secretary and the served Indian 
                [tribe or t]Tribes have jointly determined 
                that--
                          (i)[(I)] the provision of such health 
                        services will not result in a denial or 
                        diminution of health services to 
                        eligible Indians[,]; and
                          (ii)[(II)] there is no reasonable 
                        alternative health facilit[y]ies or 
                        services, within or without the 
                        [servicearea of such [s]Service 
[u]Unit, available to meet the health needs of such individuals.
          (2)[(B)] ISDEAA programs.--In the case of a Tribal 
        Health Program [health facilities operated under a 
        contract entered into under the Indian Self-
        Determination Act [25 U.S.C.A. Sec. 450f et seq.]], the 
        governing body of the Indian [t]Tribe or T[t]ribal 
        O[o]rganization providing health services under such 
        Tribal Health Program [contract] is authorized to 
        determine whether health services should be provided 
        under its Funding Agreement [such contract] to 
        individuals who are not otherwise eligible for such 
        [health] services [under any other subsection of this 
        section or under any other provision of law]. In making 
        such determination[s], the governing body [of the 
        Indian tribe or tribal organization] shall take into 
        account the considerations described in clauses (i) and 
        (ii) of paragraph (1)(B) [subparagraph (A)(ii)].
          (3)[(2)] Payment for services.--
                  (A) In general.--Persons receiving health 
                services provided by the Service under [by 
                reason of] this subsection shall be liable for 
                payment of such health services under a 
                schedule of charges prescribed by the Secretary 
                which, in the judgment of the Secretary, 
                results in reimbursement in an amount not less 
                than the actual cost of providing the health 
                services. Notwithstanding section 404[1880(c)] 
                of this [the Social Security] Act [[42 U.S.C.A. 
                Sec. 1395qq(c)], section 1642(a) of this 
                title,] or any other provision of law, amounts 
                collected under this subsection, including 
                medicare, [or] medicaid or SCHIP reimbursements 
                under titles XVIII, [and] XIX, and XXI of the 
                Social Security Act [[42 U.S.C.A. 
                Sec. Sec. 1395 et seq., 1396 et seq.]], shall 
                be credited to the account of the program 
                [facility] providing the service and shall be 
                used [solely] for the purposes listed in 
                section 401(d)(2) and [provision of health 
                services within that facility. A]amounts 
                collected under this subsection shall be 
                available for expenditure within such program 
                [facility for not to exceed one fiscal year 
                after the fiscal year in which collected].
                  (B) Indigent people.--Health services may be 
                provided by the Secretary through the Service 
                under this subsection to an indigent individual 
                [person] who would not be otherwise eligible 
                for such health services but for the provisions 
                of paragraph (1) only if an agreement has been 
                entered into with a State or local government 
                under which the State or local government 
                agrees to reimburse the Service for the 
                expenses incurred by the Service in providing 
                such health services to such indigent 
                individual [person].
          (4)[(3)] Revocation of consent for services.--
                  (A) Single tribe service area.--In the case 
                of a S[s]ervice A[a]rea which serves only 
                1[one] Indian T[t]ribe, the authority of the 
                Secretary to provide health services under 
                paragraph (1)[(A)] shall terminate at the end 
                of the fiscal year succeeding the fiscal year 
                in which the governing body of the Indian 
                T[t]ribe revokes its concurrence to the 
                provision of such health services.
                  (B) Multitribal service area.--In the case of 
                a multi[-]tribal S[s]ervice A[a]rea, the 
                authority of the Secretary to provide health 
                services under paragraph (1)[(A)] shall 
                terminate at the end of the fiscal year 
                succeeding the fiscal year in which at least 51 
                percent of the number of Indian T[t]ribes in 
                the S[s]ervice A[a]rea revoke their concurrence 
                to the provision of such health services.
    (d)[(c)] Other Services.--[Purposes served in providing 
health services to otherwise ineligible individuals]
    The Service may provide health services under this 
subsection to individuals who are not eligible for health 
services provided by the Service under any other [subsection of 
this section or under any other] provision of law in order to--
          (1) achieve stability in a medical emergency[,];
          (2) prevent the spread of a communicable disease or 
        otherwise deal with a public health hazard[,];
          (3) provide care to non-Indian women pregnant with an 
        eligible Indian's child for the duration of the 
        pregnancy through post[ ]partum[,]; or
          (4) provide care to immediate family members of an 
        eligible individual [person] if such care is directly 
        related to the treatment of the eligible individual 
        [person].
    (e)[(d) Extension of h]Hospital [p]Privileges for [to non-
Service health care p]Practitioners
    Hospital privileges in health facilities operated and 
maintained by the Service or operated under a Funding Agreement 
[contract entered into under the Indian Self-Determination Act 
[25 U.S.C.A. Sec. 450f et seq.]] may be extended to non-Service 
health care practitioners who provide services to individuals 
[persons] described in subsection (a), [or] (b), (c), or (d) 
[of this section]. Such non-Service health care practitioners 
may, as part of the privileging process, be designated 
[regarded] asemployees of the Federal Government for purposes 
of section 1346(b) and chapter 171 of Title 28, United States Code 
(relating to Federal tort claims) only with respect to acts or 
omissions which occur in the course of providing services to eligible 
individuals [persons] as a part of the conditions under which such 
hospital privileges are extended.
    (f)[(e) ``]Eligible Indian['' defined].--
    For purposes of this section, the term [``]`eligible 
Indian'[''] means any Indian who is eligible for health 
services provided by the Service without regard to the 
provisions of this section.

[Sec. 1680d. Infant and maternal mortality; fetal alcohol syndrome

    [By no later than January 1, 1990, the Secretary shall 
develop and begin implementation of a plan to achieve the 
following objectives by January 1, 1994:
          [(1) reduction of the rate of Indian infant mortality 
        in each area office of the Service to the lower of--
                  [(A) twelve deaths per one thousand live 
                births, or
                  [(B) the rate of infant mortality applicable 
                to the United States population as a whole;
          [(2) reduction of the rate of maternal mortality in 
        each area office of the Service to the lower of--
                  [(A) five deaths per one hundred thousand 
                live births, or
                  [(B) the rate of maternal mortality 
                applicable to the United States population as a 
                whole; and
          [(3) reduction of the rate of fetal alcohol syndrome 
        among Indians served by, or on behalf of, the Service 
        to one per one thousand births.

[Sec. 1680e. Contract health services for the Trenton Service Area

    [(a) Service to Turtle Mountain Band
    [The Secretary, acting through the Service, is directed to 
provide contract health services to members of the Turtle 
Mountain Band of Chippewa Indians that reside in the Trenton 
Service Area of Divide, McKenzie, and Williams counties in the 
State of North Dakota and the adjoining counties of Richland, 
Roosevelt, and Sheridan in the State of Montana.
    [(b) Band member eligibility not expanded
    [Nothing in this section may be construed as expanding the 
eligibility of members of the Turtle Mountain Band of Chippewa 
Indians for health services provided by the Service beyond the 
scope of eligibility for such health services that applied on 
May 1, 1986.

[Sec. 1680f. Indian Health Service and Department of Veterans Affairs 
                    health facilities and services sharing

    [(a) Feasibility study and report
    [The Secretary shall examine the feasibility of entering 
into an arrangement for the sharing of medical facilities and 
services between the Indian Health Service and the Department 
of Veterans Affairs and shall, in accordance with subsection 
(b) of this section, prepare a report on the feasibility of 
such an arrangement and submit such report to the Congress by 
no later than September 30, 1990.
    [(b) Nonimpairment of service quality, eligibility, or 
priority of access
    [The Secretary shall not take any action under this section 
or under subchapter IV of chapter 81 of Title 38 which would 
impair--
          [(1) the priority access of any Indian to health care 
        services provided through the Indian Health Service;
          [(2) the quality of health care services provided to 
        any Indian through the Indian Health Service;
          [(3) the priority access of any veteran to health 
        care services provided by the Department of Veterans 
        Affairs;
          [(4) the quality of health care services provided to 
        any veteran by the Department of Veterans Affairs;
          [(5) the eligibility of any Indian to receive health 
        services through the Indian Health Service; or
          [(6) the eligibility of any Indian who is a veteran 
        to receive health services through the Department of 
        Veterans Affairs.
    [(c) Cross utilization of services 
          [(1) Not later than December 23, 1988, the Director 
        of the Indian Health Service and the Secretary of 
        Veterans Affairs shall implement an agreement under 
        which--
                  [(A) individuals in the vicinity of 
                Roosevelt, Utah, who are eligible for health 
                care from the Department of Veterans Affairs 
                could obtain health care services at the 
                facilities of the Indian Health Service located 
                at Fort Duchesne, Utah; and
                  [(B) individuals eligible for health care 
                from the Indian Health Service at Fort 
                Duchesne, Utah, could obtain health care 
                services at the George E. Wahlen Department of 
                Veterans Affairs Medical Center located in Salt 
                Lake City, Utah.
          [(2) Not later than November 23, 1990, the Secretary 
        and the Secretary of Veterans Affairs shall jointly 
        submit a report to the Congress on the health care 
        services provided as a result of paragraph (1).
    [(d) Right to health services
    [Nothing in this section may be construed as creating any 
right of a veteran to obtain health services from the Indian 
Health Service except as provided in an agreement under 
subsection (c) of this section.]

Sec. 1680g. Reallocation of B[b]ase R[r]esources

    (a) Report Required.--[to Congress]
    Notwithstanding any other provision of law, any allocation 
of Service funds for a fiscal year that reduces by 5 percent or 
more from the previous fiscal year the funding for any 
recurring program, project, or activity of a S[s]ervice U[u]nit 
may be implemented only after the Secretary has submitted to 
the President, for inclusion in the report required to be 
transmitted to [the] Congress under section 801[1671 of this 
title], a report on the proposed change in allocation of 
funding, including the reasons for the change and its likely 
effects.
    (b) Exception.--[Appropriated amounts]
    Subsection (a) [of this section] shall not apply if the 
total amount appropriated to the Service for a fiscal year is 
at least 5 percent less than the amount appropriated to the 
Service for the previous fiscal year.

[Sec. 1680h. Demonstration projects for tribal management of health 
                    care services

    [(a) Establishment; grants
          [(1) The Secretary, acting through the Service, shall 
        make grants to Indian tribes to establish demonstration 
        projects under which the Indian tribe will develop and 
        test a phased approach to assumption by the Indian 
        tribe of the health care delivery system of the Service 
        for members of the Indian tribe living on or near the 
        reservations of the Indian tribe through the use of 
        Service, tribal, and private sector resources.
          [(2) A grant may be awarded to an Indian tribe under 
        paragraph (1) only if the Secretary determines that the 
        Indian tribe has the administrative and financial 
        capabilities necessary to conduct a demonstration 
        project described in paragraph (1).
    [(b) Health care contracts
    [During the period in which a demonstration project 
established under subsection (a) of this section is being 
conducted by an Indian tribe, the Secretary shall award all 
health care contracts, including community, behavioral, and 
preventive health care contracts, to the Indian tribe in the 
form of a single grant to which the regulations prescribed 
under part A of title XIX of the Public Health Service Act [42 
U.S.C.A. Sec. 300w et seq. (as modified as necessary by any 
agreement entered into between the Secretary and the Indian 
tribe to achieve the purposes of the demonstration project 
established under subsection (a) of this section) shall apply.
    [(c) Waiver of procurement laws
    [The Secretary may waive such provisions of Federal 
procurement law as are necessary to enable any Indian tribe to 
develop and test administrative systems under the demonstration 
project established under subsection (a) of this section, but 
only if such waiver does not diminish or endanger the delivery 
of health care services to Indians.
    [(d) Termination; evaluation and report
          [(1) The demonstration project established under 
        subsection (a) of this section shall terminate on 
        September 30, 1993, or, in the case of a demonstration 
        project for which a grant is made after September 30, 
        1990, three years after the date on which such grant is 
        made.
          [(2) By no later than September 30, 1996, the 
        Secretary shall evaluate the performance of each Indian 
        tribe that has participated in a demonstration project 
        established under subsection (a) of this section and 
        shall submit to the Congress a report on such 
        evaluations and demonstration projects.
    [(e) Joint venture demonstration projects
          [(1) The Secretary, acting through the Service, shall 
        make arrangements with Indian tribes to establish joint 
        venture demonstrative projects under which an Indian 
        tribe shall expend tribal, private, or other available 
        nontribal funds, for the acquisition or construction of 
        a health facility for a minimum of 20 years, under a 
        no-cost lease, in exchange for agreement by the Service 
        to provide the equipment, supplies, and staffing for 
        the operation and maintenance of such a health 
        facility. A tribe may utilize tribal funds, private 
        sector, or other available resources, including loan 
        guarantees, to fulfill its commitment under this 
        subsection.
          [(2) The Secretary shall make such an arrangement 
        with an Indian tribe only if the Secretary first 
        determines that the Indian tribe has the administrative 
        and financial capabilities necessary to complete the 
        timely acquisition or construction of the health 
        facility described in paragraph (1).
          [(3) An Indian tribe or tribal organization that has 
        entered into a written agreement with the Secretary 
        under this subsection, and that breaches or terminates 
        without cause such agreement, shall be liable to the 
        United States for the amount that has been paid to the 
        tribe, or paid to a third party on the tribe's behalf, 
        under the agreement. The Secretary has the right to 
        recover tangible property (including supplies), and 
        equipment, less depreciation, and any funds expended 
        for operations and maintenance under this section. The 
        preceding sentence does not apply to any funds expended 
        for the delivery of health care services, or for 
        personnel or staffing, shall be recoverable.

[Sec. 1680i. Child sexual abuse treatment programs

    [(a) Continuation of existing demonstration programs
    [The Secretary and the Secretary of the Interior shall, for 
each fiscal year through fiscal year 1995, continue the 
demonstration programs involving treatment for child sexual 
abuse provided through the Hopi Tribe and the Assiniboine and 
Sioux Tribes of the Fort Peck Reservation.
    [(b) Establishment of new demonstration programs
    [Beginning October 1, 1995, the Secretary and the Secretary 
of the Interior may establish, in any service area, 
demonstration programs involving treatment for child sexual 
abuse, except that the Secretaries may not establish a greater 
number of such programs in one service area than in any other 
service area until there is an equal number of such programs 
established with respect to all service areas from which the 
Secretary receives qualified applications during the 
application period (as determined by the Secretary).

[Sec. 1680j. Tribal leasing

    [Indian tribes providing health care services pursuant to a 
contract entered into under the Indian Self-Determination Act 
[25 U.S.C.A. Sec. 450f et seq.] may lease permanent structures 
for the purpose of providing such health care services without 
obtaining advance approval in appropriation Acts.

[Sec. 1680k. Home- and community-based care demonstration project

    [(a) Authority of Secretary
    [The Secretary, acting through the Service, is authorized 
to enter into contracts with, or make grants to, Indian tribes 
or tribal organizations providing health care services pursuant 
to a contract entered into under the Indian Self-Determination 
Act [25 U.S.C.A. Sec. 450f et seq.], to establish demonstration 
projects for the delivery of home- and community-based services 
to functionally disabled Indians.
    [(b) Use of funds
          [(1) Funds provided for a demonstration project under 
        this section shall be used only for the delivery of 
        home- and community-based services (including 
        transportation services) to functionally disabled 
        Indians.
          [(2) Such funds may not by used--
                  [(A) to make cash payments to functionally 
                disabled Indians;
                  [(B) to provide room and board for 
                functionally disabled Indians;
                  [(C) for the construction or renovation of 
                facilities or the purchase of medical 
                equipment; or
                  [(D) for the provision of nursing facility 
                services.
    [(c) Criteria for approval of applications
    [Not later than 180 days after October 29, 1992, the 
Secretary, after consultation with Indian tribes and tribal 
organizations, shall develop and issue criteria for the 
approval of applications submitted under this section. Such 
criteria shall ensure that demonstration projects established 
under this section promote the development of the capacity of 
tribes and tribal organizations to deliver, or arrange for the 
delivery of, high quality, culturally appropriate home- and 
community-based services to functionally disabled Indians;
    [(d) Assistance to applicants
    [The Secretary shall provide such technical and other 
assistance as may be necessary to enable applicants to comply 
with the provisions of this section.
    [(e) Services to ineligible persons
    [At the discretion of the tribe or tribal organization, 
services provided under a demonstration project established 
under this section may be provided (on a cost basis) to persons 
otherwise ineligible for the health care benefits of the 
Service.
    [(f) Maximum number of demonstration projects
    [The Secretary shall establish not more than 24 
demonstration projects under this section. The Secretary may 
not establish a greater number of demonstration projects under 
this section in one service area than in any other service area 
until there is an equal number of such demonstration projects 
established with respect to all service areas from which the 
Secretary receives applications during the application period 
(as determined by the Secretary) which meet the criteria issued 
pursuant to subsection (c) of this section.
    [(g) Report
    [The Secretary shall submit to the President, for inclusion 
in the report which is required to be submitted under section 
1671 of this title for fiscal year 1999, a report on the 
findings and conclusions derived from the demonstration 
projects conducted under this section, together with 
legislative recommendations.
    [(h) Definitions
    [For the purposes of this section, the following 
definitions shall apply:
          [(1) The term ``home- and community-based services'' 
        means one or more of the following:
                  [(A) Homemaker/home health aide services.
                  [(B) Chore services.
                  [(C) Personal care services.
                  [(D) Nursing care services provided outside 
                of a nursing facility by, or under the 
                supervision of, a registered nurse.
                  [(E) Respite care.
                  [(F) Training for family members in managing 
                a functionally disabled individual.
                  [(G) Adult day care.
                  [(H) Such other home- and community-based 
                services as the Secretary may approve.
          [(2) The term ``functionally disabled'' means an 
        individual who is determined to require home- and 
        community-based services based on an assessment that 
        uses criteria (including, at the discretion of the 
        tribe or tribal organization, activities of daily 
        living) developed by the tribe or tribal organization.
    [(i) Authorization of appropriations
    [There are authorized to be appropriated for each of the 
fiscal years 1996 through 2000 such sums as may be necessary to 
carry out this section. Such sums shall remain available until 
expended.

[Sec. 1680l. Shared services demonstration project

    [(a) Authority of Secretary
    [The Secretary, acting through the Service and 
notwithstanding any other provision of law, is authorized to 
enter into contracts with Indian tribes or tribal organizations 
to establish not more than 6 shared services demonstration 
projects for the delivery of long-term care to Indians. Such 
projects shall provide for the sharing of staff or other 
services between a Service facility and a nursing facility 
owned and operated (directly or by contract) by such Indian 
tribe ortribal organization.
    [(b) Contract requirements
    [A contract entered into pursuant to subsection (a) of this 
section--
          [(1) may, at the request of the Indian tribe or 
        tribal organization, delegate to such tribe or tribal 
        organization such powers of supervision and control 
        over Service employees as the Secretary deems necessary 
        to carry out the purposes of this section;
          [(2) shall provide that expenses (including salaries) 
        relating to services that are shared between the 
        Service facility and the tribal facility be allocated 
        proportionately between the Service and the tribe or 
        tribal organization; and
          [(3) may authorize such tribe or tribal organization 
        to construct, renovate, or expand a nursing facility 
        (including the construction of a facility attached to a 
        Service facility), except that no funds appropriated 
        for the Service shall be obligated or expended for such 
        purpose.
    [(c) Eligibility
    [To be eligible for a contract under this section, a tribe 
or tribal organization, shall, as of October 29, 1992--
          [(1) own and operate (directly or by contract) a 
        nursing facility;
          [(2) have entered into an agreement with a consultant 
        to develop a plan for meeting the long-term needs of 
        the tribe or tribal organization; or
          [(3) have adopted a tribal resolution providing for 
        the construction of a nursing facility.
    [(d) Nursing facilities
    [Any nursing facility for which a contract is entered into 
under this section shall meet the requirements for nursing 
facilities under section 1396r or Title 42.
    [(e) Assistance to applicants
    [The Secretary shall provide such technical and other 
assistance as may be necessary to enable applicants to comply 
with the provisions of this section.
    [(f) Report
    [The Secretary shall submit to the President, for inclusion 
in each report required to be transmitted to the Congress under 
section 1671 of this title, a report on the findings and 
conclusions derived from the demonstration projects conducted 
under this section.]

Sec. 1680m. Results of [d]Demonstration [p]Projects

    The Secretary shall provide for the dissemination to Indian 
T[t]ribes, Tribal Organizations, and Urban Indian Organizations 
of the findings and results of demonstration projects conducted 
under this Act [chapter].

[Sec. 1680n. Priority for Indian reservations

    [(a) Facilities and projects
    [Beginning on October 29, 1992, the Bureau of Indian 
Affairs and the Service shall, in all matters involving the 
reorganization or development of service facilities, or in the 
establishment of related employment projects to address 
unemployment conditions in economically depressed areas, give 
priority to locating such facilities and projects on Indian 
lands if requested by the Indian tribe with jurisdiction over 
such lands.
    [(b) ``Indian lands'' defined
    [For purposes of this section, the term ``Indian lands'' 
means--
          [(1) all lands within the limits of any Indian 
        reservation; and
          [(2) any lands title which is held in trust by the 
        United States for the benefit of any Indian tribe or 
        individual Indian, or held by any Indian tribe or 
        individual Indian subject to restriction by the United 
        States against alienation and over which an Indian 
        tribe exercises governmental power.]

Sec. 810. Provision of Services in Montana

    (a) Consistent with Court Decision.--The Secretary, acting 
through the Service, shall provide services and benefits for 
Indians in Montana in a manner consistent with the decision of 
the United States Court of Appeals for the Ninth Circuit in 
McNabb for McNabb v. Bowen, 829 F.2d 787 (9th Cir. 1987).
    (b) Clarification.--The provisions of subsection (a) shall 
not be construed to be an expression of the sense of Congress 
on the application of the decision described in subsection (a) 
with respect to the provision of services or benefits for 
Indians living in any State other than Montana.

[Sec. 1680o. Authorization of appropriations

    [Except as provided in section 1680k of this title, there 
are authorized to be appropriated such sums as may be necessary 
for each fiscal year through fiscal year 2000 to carry out this 
subchapter.]

Sec. 811. Moratorium.

    During the period of the moratorium imposed on 
implementation of the final rule published in the Federal 
Register on September 16, 1987, by the Health Resources and 
Services Administration of the Public Health Service, relating 
to eligibility for the health care services of the Indian 
Health Service, the Indian Health Service shall provide 
services pursuant to the criteria for eligibility for such 
services that were in effect on September 15, 1987, subject to 
the provisions of sections 806 and 807 until such time as new 
criteria governing eligibility for services are developed in 
accordance with section 802.

[Sec. 1681. Omitted]

Sec. 812. Tribal Employment.

    For purposes of section 2(2) of the Act of July 5, 1935 (49 
Stat. 450, chapter 372), an Indian Tribe or Tribal Organization 
carrying out a Funding Agreement shall not be considered an 
`employer'.

[Sec. 1682. Subrogation of claims by Indian Health Service

    [On and after October 18, 1986, the Indian Health Service 
may seek subrogation of claims including but not limited to 
auto accident claims, including no-fault claims, personal 
injury, disease, or disability claims, and worker's 
compensation claims, the proceeds of which shall be credited to 
the funds established by sections 401 and 402 of the Indian 
Health Care Improvement Act.]

Sec. 813. Prime Vendor.

    (a) Executive Agency Status.--For purposes of section 
201(a) of the Federal Property and Administrative Services Act 
(40 U.S.C. 481(a)) (relating to Federal sources of supply, 
including lodging providers, airlines, and other transportation 
providers), a Tribal Health Program shall be deemed an 
executive agency when carrying out a contract, grant, 
cooperative agreement, or Funding Agreement with the Service 
and shall have access to the Federal Supply Schedule and any 
other Federal source of supply to which executive agencies have 
access.
    (b) IHS Status.--For purposes of section 4 of Public Law 
102-585 (38 U.S.C. 8126), a Tribal Health Program shall have 
the status of the Indian Health Service and shall have direct 
access to the Veterans Administration prime vendor provided for 
in section 4 of Public Law 102-585.
    (c) Employee Status.--The employees of such Tribal Health 
Programs may order supplies under such respective programs on 
the same basis as employees of the Service.

[Sec. 1683. Indian Catastrophic Health Emergency Fund

    [$10,000,000 shall remain available until expended, for the 
establishment of an Indian Catastrophic Health Emergency Fund 
(hereinafter referred to as the ``Fund''). On and after October 
18, 1986, the Fund is to cover the Indian Health Service 
portion of the medical expenses of catastrophic illness falling 
within the responsibility of the Service and shall be 
administered by the Secretary of Health and Human Services, 
acting through the central office of the Indian Health Service. 
No part of the Fund or its administration shall be subject to 
contract or grant under the Indian Self-Determination and 
Education Assistance Act (Public Law 93-638) [25 U.S.C.A. 
Sec. 450 et seq.]. There shall be deposited into the Fund all 
amounts recovered under the authority of the Federal Medical 
Care Recovery Act (42 U.S.C. 2651 et seq.), which shall become 
available for obligation upon receipt and which shall remain 
available for obligation until expended. The Fund shall not be 
used to pay for health services provided to eligible Indians to 
the extent that alternate Federal, State, local, or private 
insurance resources for payment: (1) are available and 
accessible to the beneficiary; or (2) would be available and 
accessible if the beneficiary were to apply for them; or (3) 
would be available and accessible to other citizens similarly 
situated under Federal, State, or local law or regulation or 
private insurance program notwithstanding Indian Health Service 
eligibility or residency on or off a Federal Indian 
reservation.]

Sec. 814. Severability Provisions.

    If any provision of this Act, any amendment made by theAct, 
or the application of such provision or amendment to any person or 
circumstances is held to be invalid, the remainder of this Act, the 
remaining amendments made by this Act, and the application of such 
provisions to persons or circumstances other than those to which it is 
held invalid, shall not be affected thereby.

Sec. 815. Establishment of National Bipartisan Commission on Indian 
                    Health Care Entitlement.

    (a) Establishment.--There is hereby established the 
National Bipartisan Indian Health Care Entitlement Commission 
(the `Commission').
    (b) Duties of Commission.--The duties of the Commission are 
the following:
          (1) To establish a study committee composed of those 
        members of the Commission appointed by the Director and 
        at least 4 members of Congress from among the members 
        of the Commission, the duties of which shall be the 
        following:
                  (A) To the extent necessary to carry out its 
                duties, collect and compile data necessary to 
                understand the extent of Indian needs with 
                regard to the provision of health services, 
                regardless of the location of Indians, 
                including holding hearings and soliciting the 
                views of Indians, Indian Tribes, Tribal 
                Organizations, and Urban Indian Organizations, 
                which may include authorizing and making funds 
                available for feasibility studies of various 
                models for providing and funding health 
                services for all Indian beneficiaries, 
                including those who live outside of a 
                reservation, temporarily or permanently.
                  (B) To make recommendations to the Commission 
                for legislation that will provide for the 
                delivery of health services for Indians as an 
                entitlement, which will address, among other 
                things, issues of eligibility, benefits to be 
                provided, including recommendations regarding 
                from whom such health services are to be 
                provided and the cost, including mechanisms for 
                making funds available for the health services 
                to be provided.
                  (C) To determine the effect of the enactment 
                of such recommendations on (i) the existing 
                system of delivery of health services for 
                Indians, and (ii) the sovereign status of 
                Indian Tribes.
                  (D) Not later than 12 months after the 
                appointment of all members of the Commission, 
                to submit a written report of its findings and 
                recommendations to the full Commission. The 
                report shall include a statement of the 
                minority and majority position of the Committee 
                and shall be disseminated, at a minimum, to 
                every Indian Tribe, Tribal Organization, and 
                Urban Indian Organization for comment to the 
                Commission.
                  (E) To report regularly to the full 
                Commission regarding the findings and 
                recommendations developed by the study 
                committee in the course of carrying out its 
                duties under this section.
          (2) To review and analyze the recommendations of the 
        report of the study committee.
          (3) To make recommendations to Congress for providing 
        health services for Indians as an entitlement, giving 
        due regard to the effects of such a program on existing 
        health care delivery systems for Indians and the effect 
        of such a program on the sovereign status of Indian 
        Tribes.
          (4) Not later than 18 months following the date of 
        appointment of all members of the Commission, submit a 
        written report to Congress containing a recommendation 
        of policies and legislation to implement a policy that 
        would establish a health care system for Indians based 
        on delivery of health services as an entitlement, 
        together with a determination of the implications of 
        such an entitlement system on existing health care 
        delivery systems for Indians on the sovereign status of 
        Indian Tribes.
    (c) Members.--
          (1) Appointment.--The Commission shall be composed of 
        25 members, appointed as follows:
                  (A) Ten members of Congress, including 3 from 
                the House of Representatives and 2 from the 
                Senate, appointed by their respective majority 
                leaders, and 3 from the House of 
                Representatives and 2 from the Senate, 
                appointed by their respective minority leaders, 
                and who shall be members of the standing 
                committees of Congress that consider 
                legislation affecting health care to Indians.
                  (B) Twelve persons chosen by the 
                congressional members of the Commission, 1 from 
                each Service Area as currently designated by 
                the Director to be chosen from among 3 nominees 
                from each Service Area put forward by the 
                Indian Tribes within the area, with due regard 
                being given to the experience and expertise of 
                the nominees in the provision of health care 
toIndians and to a reasonable representation on the commission of 
members who are familiar with various health care delivery modes and 
who represent Indian Tribes of various size populations.
                  (C) Three persons appointed by the Director 
                who are knowledgeable about the provision of 
                health care to Indians, at least 1 of whom 
                shall be appointed from among 3 nominees put 
                forward by those programs whose funds are 
                provided in whole or in part by the Service 
                primarily or exclusively for the benefit of 
                Urban Indians.
                  (D) All those persons chosen by the 
                congressional members of the Commission and by 
                the Director shall be members of federally 
                recognized Indian Tribes.
          (2) Chair; vice chair.--The Chair and Vice Chair of 
        the Commission shall be selected by the congressional 
        members of the Commission.
          (3) Terms.--The terms of members of the Commission 
        shall be for the life of the Commission.
          (4) Deadline for appointments.--Congressional members 
        of the Commission shall be appointed not later than 90 
        days after the date of the enactment of the Indian 
        Health Care Improvement Act Amendments of 2004, and the 
        remaining members of the Commission shall be appointed 
        not later than 60 days following the appointment of the 
        congressional members.
          (5) Vacancy.--A vacancy in the Commission shall be 
        filled in the manner in which the original appointment 
        was made.
    (d) Compensation.--
          (1) Congressional members.--Each congressional member 
        of the Commission shall receive no additional pay, 
        allowances, or benefits by reason of their service on 
        the Commission and shall receive travel expenses and 
        per diem in lieu of subsistence in accordance with 
        sections 5702 and 5703 of title 5, United States Code.
          (2) Other members.--Remaining members of the 
        Commission, while serving on the business of the 
        Commission (including travel time), shall be entitled 
        to receive compensation at the per diem equivalent of 
        the rate provided for level IV of the Executive 
        Schedule under section 5315 of title 5, United States 
        Code, and while so serving away from home and the 
        member's regular place of business, a member may be 
        allowed travel expenses, as authorized by the Chairman 
        of the Commission. For purpose of pay (other than pay 
        of members of the Commission) and employment benefits, 
        rights, and privileges, all personnel of the Commission 
        shall be treated as if they were employees of the 
        United States Senate.
    (e) Meetings.--The Commission shall meet at the call of the 
Chair.
    (f) Quorum.--A quorum of the Commission shall consist of 
not less than 15 members, provided that no less than 6 of the 
members of Congress who are Commission members are present and 
no less than 9 of the members who are Indians are present.
    (g) Executive Director; Staff; Facilities.--
          (1) Appointment; pay.--The Commission shall appoint 
        an executive director of the Commission. The executive 
        director shall be paid the rate of basic pay for level 
        V of the Executive Schedule.
          (2) Staff appointment.--With the approval of the 
        Commission, the executive director may appoint such 
        personnel as the executive director deems appropriate.
          (3) Staff pay.--The staff of the Commission shall be 
        appointed without regard to the provisions of title 5, 
        United States Code, governing appointments in the 
        competitive service, and shall be paid without regard 
        to the provisions of chapter 51 and subchapter III of 
        chapter 53 of such title (relating to classification 
        and General Schedule pay rates).
          (4) Temporary services.--With the approval of the 
        Commission, the executive director may procure 
        temporary and intermittent services under section 
        3109(b) of title 5, United States Code.
          (5) Facilities.--The Administrator of General 
        Services shall locate suitable office space for the 
        operation of the Commission. The facilities shall serve 
        as the headquarters of the Commission and shall include 
        all necessary equipment and incidentals required for 
        the proper functioning of the Commission.
    (h) Hearings.--
          (1) For the purpose of carrying out its duties, the 
        Commission may hold such hearings and undertake such 
        other activities as the Commission determines to be 
        necessary to carry out its duties, provided that at 
        least 6 regional hearings areheld in different areas of 
the United States in which large numbers of Indians are present. Such 
hearings are to be held to solicit the views of Indians regarding the 
delivery of health care services to them. To constitute a hearing under 
this subsection, at least 5 members of the Commission, including at 
least 1 member of Congress, must be present. Hearings held by the study 
committee established in this section may count toward the number of 
regional hearings required by this subsection.
          (2) Upon request of the Commission, the Comptroller 
        General shall conduct such studies or investigations as 
        the Commission determines to be necessary to carry out 
        its duties.
          (3)(A) The Director of the Congressional Budget 
        Office or the Chief Actuary of the Centers for Medicare 
        & Medicaid Services, or both, shall provide to the 
        Commission, upon the request of the Commission, such 
        cost estimates as the Commission determines to be 
        necessary to carry out its duties.
          (B) The Commission shall reimburse the Director of 
        the Congressional Budget Office for expenses relating 
        to the employment in the office of the Director of such 
        additional staff as may be necessary for the Director 
        to comply with requests by the Commission under 
        subparagraph (A).
          (4) Upon the request of the Commission, the head of 
        any Federal agency is authorized to detail, without 
        reimbursement, any of the personnel of such agency to 
        the Commission to assist the Commission in carrying out 
        its duties. Any such detail shall not interrupt or 
        otherwise affect the civil service status or privileges 
        of the Federal employee.
          (5) Upon the request of the Commission, the head of a 
        Federal agency shall provide such technical assistance 
        to the Commission as the Commission determines to be 
        necessary to carry out its duties.
          (6) The Commission may use the United States mails in 
        the same manner and under the same conditions as 
        Federal agencies and shall, for purposes of the frank, 
        be considered a commission of Congress as described in 
        section 3215 of title 39, United States Code.
          (7) The Commission may secure directly from any 
        Federal agency information necessary to enable it to 
        carry out its duties, if the information may be 
        disclosed under section 552 of title 4, United States 
        Code. Upon request of the Chairman of the Commission, 
        the head of such agency shall furnish such information 
        to the Commission.
          (8) Upon the request of the Commission, the 
        Administrator of General Services shall provide to the 
        Commission on a reimbursable basis such administrative 
        support services as the Commission may request.
          (9) For purposes of costs relating to printing and 
        binding, including the cost of personnel detailed from 
        the Government Printing Office, the Commission shall be 
        deemed to be a committee of Congress.
    (i) Authorization of Appropriations.--There is authorized 
to be appropriated $4,000,000 to carry out the provisions of 
this section, which sum shall not be deducted from or affect 
any other appropriations for health care for Indian persons.
    (j) FACA.--The Federal Advisory Committee Act (5 U.S.C. 
App.) shall not apply to the Commission.

Sec. 816. Appropriations; Availability.

    Any new spending authority (described in subsection 
(c)(2)(A) or (B) of section 401 of the Congressional Budget Act 
of 1974) which is provided under this Act shall be effective 
for any fiscal year only to such extent or in such amounts as 
are provided in appropriation Acts.

Sec. 817. Confidentiality of Medical Quality Assurance Records: 
                    Qualified Immunity for Participants

    (a) Confidentiality of Records.--Medical quality assurance 
records created by or for any Indian Health Program or a health 
program of an Urban Indian Organization as part of a medical 
quality assurance program are confidential and privileged. Such 
records may not be disclosed to any person or entity, except as 
provided in subsection (c).
    (b) Prohibition on Disclosure and Testimony.--
          (1) No part of any medical quality assurance record 
        described in subsection (a) may be subject to discovery 
        or admitted into evidence in any judicial or 
        administrative proceeding, except as provided in 
        subsection (c).
          (2) A person who reviews or creates medical quality 
        assurance records for any Indian health program or 
        Urban Indian Organization who participates in any 
        proceeding that reviews or creates such records may not 
        be permitted or required to testify in any judicial or 
        administrative proceeding with respect to such records 
        or with respect to any finding, 
recommendation,evaluation, opinion, or action taken by such person or 
body in connection with such records except as provided in this 
section.
    (c) Authorized Disclosure and Testimony.--
          (1) Subject to paragraph (2), a medical quality 
        assurance record described in subsection (a) may be 
        disclosed, and a person referred to in subsection (b) 
        may give testimony in connection with such a record, 
        only as follows:
                  (A) To a Federal executive agency or private 
                organization, if such medical quality assurance 
                record or testimony is needed by such agency or 
                organization to perform licensing or 
                accreditation functions related to any Indian 
                Health Program or to a health program of an 
                Urban Indian Organization to perform 
                monitoring, required by law, of such program or 
                organization.
                  (B) To an administrative or judicial 
                proceeding commenced by a present or former 
                Indian Health Program or Urban Indian 
                Organization provider concerning the 
                termination, suspension, or limitation of 
                clinical privileges of such health care 
                provider.
                  (C) To a governmental board or agency or to a 
                professional health care society or 
                organization, if such medical quality assurance 
                record or testimony is needed by such board, 
                agency, society, or organization to perform 
                licensing, credentialing, or the monitoring of 
                professional standards with respect to any 
                health care provider who is or was an employee 
                of any Indian Health Program or Urban Indian 
                Organization.
                  (D) To a hospital, medical center, or other 
                institution that provides health care services, 
                if such medical quality assurance record or 
                testimony is needed by such institution to 
                assess the professional qualifications of any 
                health care provider who is or was an employee 
                of any Indian Health Program or Urban Indian 
                Organization and who has applied for or been 
                granted authority or employment to provide 
                health care services in or on behalf of such 
                program or organization.
                  (E) To an officer, employee, or contractor of 
                the Indian Health Program or Urban Indian 
                Organization that created the records or for 
                which the records were created. If that 
                officer, employee, or contractor has a need for 
                such record or testimony to perform official 
                duties.
                  (F) To a criminal or civil law enforcement 
                agency or instrumentality charged under 
                applicable law with the protection of the 
                public health or safety, if a qualified 
                representative of such agency or 
                instrumentality makes a written request that 
                such record or testimony be provided for a 
                purpose authorized by law.
                  (G) In an administrative or judicial 
                proceeding commenced by a criminal or civil law 
                enforcement agency or instrumentality referred 
                to in subparagraph (F), but only with respect 
                to the subject of such proceeding.
          (2) With the exception of the subject of a quality 
        assurance action, the identity of any person receiving 
        health care services from any Indian Health Program or 
        Urban Indian Organization or the identity of any other 
        person associated with such program or organization for 
        purposes of a medical quality assurance program that is 
        disclosed in a medical quality assurance record 
        described in subsection (a) shall be deleted from that 
        record or document before any disclosure of such record 
        is made outside such program or organization. Such 
        requirement does not apply to the release of 
        information pursuant to section 552a of title 5.
    (d) Disclosure for Certain Purposes.--
          (1) Nothing in this section shall be construed as 
        authorizing or requiring the withholding from any 
        person or entity aggregate statistical information 
        regarding the results of any Indian Health Program or 
        Urban Indian Organizations's medical quality assurance 
        programs.
          (2) Nothing in this section shall be construed as 
        authority to withhold any medical quality assurance 
        record from a committee of either House of Congress, 
        any joint committee of Congress, or the Government 
        Accountability Office if such record pertains to any 
        matter within their respective jurisdictions.
    (e) Prohibition on Disclosure of Record or Testimony.--A 
person or entity having possession of or access to a record or 
testimony described by this section may not disclose the 
contents of such record or testimony in any manner or for any 
purpose except as provided in this section.
    (f) Exemption from Freedom of Information Act.--Medical 
quality assurance records described in subsection (a) may not 
be made available to any person under section 552 of title 5.
    (g) Limitation on Civil Liability.--A person who 
participates in or provides information to a person or body 
that reviews or creates medical quality assurance records 
described in subsection (a) shall not be civilly liable for 
suchparticipation or for providing such information if the 
participation or provision of information was in good faith based on 
prevailing professional standards at the time the medical quality 
assurance program activity took place.
    (h) Application to Information in Certain Other Records.-- 
Nothing in this section shall be construed as limiting access 
to the information in a record created and maintained outside a 
medical quality assurance program, including a patient's 
medical records, on the grounds that the information was 
presented during meetings of a review body that the information 
was presented during meetings of a review body that are part of 
a medical quality assurance program.
    (i) Regulations.--The Secretary, acting through the 
Service, shall promulgate regulations pursuant to section 802 
of this title.
    (j) Definitions.--In this section:
          (1) The term `medical quality assurance program' 
        means any activity carried out before, on, or after the 
        date of enactment of this Act by or for any Indian 
        Health Program or Urban Indian Organization to assess 
        the quality of medical care, including activities 
        conducted by or on behalf of individuals, Indian Health 
        Program or Urban Indian Organization medical or dental 
        treatment review committees, or other review bodies 
        responsible for quality assurance, credentials, 
        infection control, patient care assessment (including 
        treatment procedures, blood, drugs, and therapeutics), 
        medical records, health resources management review and 
        identification and prevention of medical or dental 
        incidents and risks.
          (2) The term `medical quality assurance record' means 
        the proceedings, records, minutes, and reports that 
        emanate from quality assurance program activities 
        described in paragraph (1) and are produced or compiled 
        by or for an Indian Health Program or Urban Indian 
        Organization as part of a medical quality assurance 
        program.
          (3) The term `health care provider' means any health 
        care professional, including community health aides and 
        practitioners certified under section 121, who are 
        granted clinical practice privileges or employed to 
        provide health care services in an Indian Health 
        Program or health program of an Urban Indian 
        Organization, who is licensed or certified to perform 
        health care services by a governmental board or agency 
        or professional health care society or organization.

Sec. 818. Authorization of Appropriations.

    (a) In General.--There are authorized to be appropriated 
such sums as may be necessary for each fiscal year through 
fiscal year 2015 to carry out this title.
    (b) Rate of Pay.--
          (1) Positions at level iv.--Section 5315 of title 5, 
        United States Code, is amended by striking ``Assistant 
        Secretaries of Health and Human Services (6).'' and 
        inserting ``Assistant Secretaries of Health and Human 
        Services (7)''.
          (2) Positions at level v.--Section 5316 of title 5, 
        United States Code, is amended by striking ``Director, 
        Indian Health Service, Department of Health and Human 
        Services''.
    (c) Three Affiliated Tribes Health Facility Compensation.--
          (1) Findings.--Congress finds that--
                  (A) in 1949, the United States assumed 
                jurisdiction over more that 150,000 prime acres 
                on the Fort Berthold Indian Reservation, North 
                Dakota, for the construction of the Garrison 
                Dam and Reservoir;
                  (B) the reservoir flooded and destroyed vital 
                infrastructure on the reservation, including a 
                hospital of the Indian Health Service;
                  (C) the United States made a commitment to 
                the Three Affiliated Tribes of the Fort 
                Berthold Indian Reservation to replace the lost 
                infrastructure;
                  (D) on May 10, 1985, the Secretary of the 
                Interior established the Garrison Unit Joint 
                Tribal Advisory Committee to examine the 
                effects of the Garrison Dam and Reservoir on 
                the Fort Berthold Indian Reservation;
                  (E) the final report of the Committee issued 
                on May 23, 1986, acknowledged the obligation of 
                the Federal Government to replace the 
                infrastructure destroyed by the Federal action;
                  (F) the Committee on Indian Affairs of the 
                Senate--
                          (i) acknowledged the recommendations 
                        of the final report of the Committee in 
                        Senate Report No. 102-250; and
                          (ii) stated that every effort should 
                        be made bythe Administration and 
Congress to provide additional Federal funding to replace the lost 
infrastructure; and
                  (G) on August 30, 2001, the Chairman of the 
                Three Affiliated Tribes testified before the 
                Committee on Indian Affairs of the Senate that 
                the promise to replace the lost infrastructure, 
                particularly the hospital, still had not been 
                kept.
          (2) Rural health care facility, fort berthold indian 
        reservation, north dakota.--The Three Affiliated Tribes 
        and Standing Rock Sioux Tribe Equitable Compensation 
        Act is amended--

           *       *       *       *       *       *       *


                       UNITED STATES PUBLIC LAWS


                     102D CONGRESS--SECOND SESSION


                      PL 102-575, OCTOBER 30, 1992


     RECLAMATION PROJECTS AUTHORIZATION AND ADJUSTMENT ACT OF 1992


SEC. 3504. FUNDS.

    (a) Three Affiliated Tribes Economic Recovery Fund.--
          (1) There is established in the Treasury of the 
        United States the ``Three Affiliated Tribes Economic 
        Recovery Fund'' (hereinafter referred to as the 
        ``Recovery Fund'').
          (2) Commencing with fiscal year 1993, and each fiscal 
        year thereafter, the Secretary of the Treasury shall 
        deposit in the Three Affiliated Tribes Economic 
        Recovery Fund an amount, which shall be nonreimbursable 
        and nonreturnable equal to 25 percent of the receipts 
        from deposits to the United States Treasury for the 
        preceding fiscal year from the integrated programs of 
        the Eastern Division of the Pick-Sloan Missouri River 
        Basin Project administered by the Western Area Power 
        Administration, but in no event shall the aggregate of 
        the amounts deposited to the Fund established by this 
        subsection for compensation for the Three Affiliated 
        Tribes pursuant to this paragraph and paragraph (3) 
        exceed $149,200,000.
          (3) For payment to the Three Affiliated Tribes of 
        amounts to which they remain entitled pursuant to the 
        Act entitled ``An Act to make certain provisions in 
        connection with the construction of the Garrison 
        Diversion unit, Missouri River Basin Project, by the 
        Secretary of the Interior,'' approved August 5, 1965 
        (79 Stat. 433), there is authorized to be appropriated 
        to the Recovery Fund established by subsection (a) for 
        fiscal year 1994 and each of the next following nine 
        fiscal years, the sum of $6,000,000.
          (4) The Secretary of the Treasury shall deposit the 
        interest which accrues on deposits to the Three 
        Affiliated Tribes Economic Recovery Fund in a separate 
        account in the Treasury of the United States. Such 
        interest shall be available, without fiscal year 
        limitation, for use by the Secretary of the Interior, 
        commencing with fiscal year 1998, and each fiscal year 
        thereafter, in making payments to the Three Affiliated 
        Tribes for use for educational, social welfare, 
        economic development, and other programs, subject to 
        the approval of the Secretary. No part of the principal 
        of the Three Affiliated Tribes Economic Development 
        Fund shall be available for making such payments.
    (b) Standing Rock Sioux Tribe Economic Recovery Fund.--
          (1) There is established in the Treasury of the 
        United States the ``Standing Rock Sioux Tribe Economic 
        Recovery Fund.''
          (2) Commencing with fiscal year 1993, and for each 
        fiscal year thereafter, the Secretary of the Treasury 
        shall deposit in the Standing Rock Sioux Tribe Economic 
        Recovery Fund an amount, which shall be nonreimbursable 
        and nonreturnable equal to 25 percent of the receipts 
        from deposits to the United States Treasury for the 
        preceding fiscal year from the integrated programs of 
        the Eastern Division of the Pick-Sloan Missouri River 
        Basin Project administered by the Western Area Power 
        Administration, but in no event shall the aggregate of 
        the amounts deposited to the Recovery Fund established 
        by this subsection for compensation for the Standing 
        Rock Sioux Tribe pursuant to this paragraph exceed 
        $90,600,000.
          (3) The Secretary of the Treasury shall deposit the 
        interest which accrues on deposits to the Standing Rock 
        Sioux Tribe Economic Recovery Fund in a separate 
        account in the Treasury of the United States. Such 
        interest shall be available, without fiscal year 
        limitation, for use by the Secretary of the Interior, 
        commencing with fiscal year 1998, and each fiscal year 
        thereafter, in making payments to the Standing Rock 
        Sioux Tribe for use for educational, social welfare, 
        economic development, and other programs, subject to 
        the approval of the Secretary. No part of the principal 
        of the Standing Rock Sioux Tribe Economic Recovery Fund 
        shall be available for making such payments.
    (c) Authorization of Appropriations.--There are authorized 
to be appropriated such sums as are necessary to carry out this 
section.

[SEC. 3511. AUTHORIZATION.

    [There are authorized to be appropriated such sums as may 
be necessary to carry out the provisions of section 3504 of 
this title.]

Sec. 3511. Rural Health Care Facility, Fort Berthold Indian 
                    Reservation, North Dakota

    There are authorized to be appropriated to the Secretary of 
Health and Human Services $20,000,000 for the construction of, 
and such sums as are necessary for other expenses relating to, 
a rural health care facility on the Fort Berthold Indian 
Reservation of the Three Affiliated Tribes, North Dakota.
                              ----------                              


                       UNITED STATES PUBLIC LAWS


                     106TH CONGRESS--SECOND SESSION


              PL 106-310, OCTOBER 17, 2000, 114 STAT. 1101


                          25 U.S.C. 1671 NOTE


                     CHILDREN'S HEALTH ACT OF 2000


SEC. 3307. ESTABLISHMENT OF COMMISSION.

    (a) In General.--There is established a commission to be 
known as the Commission on Indian and Native Alaskan Health 
Care that shall examine the health concerns of Indians and 
Native Alaskans who reside on reservations and tribal lands 
(hereafter in this section referred to as the ``Commission'').
    (b) Membership.--
          (1) In general.--The Commission established under 
        subsection (a) shall consist of--
                  (A) the Secretary;
                  (B) 15 members who are experts in the health 
                care field and issues that the Commission is 
                established to examine; and
                  (C) the [Director of the Indian Health 
                Service] Assistant Secretary for Indian Health 
                and the Commissioner of Indian Affairs, who 
                shall be nonvoting members. 

                      UNITED STATES CODE ANNOTATED


                           TITLE 25--INDIANS

               CHAPTER 41--INDIAN LANDS OPEN DUMP CLEANUP


Sec. 3902. Definitions

    For the purposes of this chapter, the following definitions 
shall apply:
          (3) Assistant secretary.--The term `Assistant 
        Secretary' means the Assistant Secretary for Indian 
        Health.
          (4)[(1)] Closure or close.--The term ``closure or 
        close'' means the termination of operations at open 
        dumps on Indian land or Alaska Native land and bringing 
        such dumps into compliance with applicable Federal 
        standards and regulations, or standards promulgated by 
        an Indian tribal government or Alaska Native entity, if 
        such standards are more stringent than the Federal 
        standards and regulations.
          [(2) Director.--The term ``Director'' means the 
        Director of the Indian Health Service.]
          (5)[(3)] Indian land.--The term ``Indian land'' 
        means--
                  (A) land within the limits of any Indian 
                reservation under the jurisdiction of the 
                United States Government, notwithstanding the 
                issuance of any patent, and including rights-
                of-way running through the reservation;
                  (B) dependent Indian communities within the 
                borders of the United States whether within the 
                original or subsequently acquired territory 
                thereof, and whether within or without the 
                limits of a State; and
                  (C) Indian allotments, the Indian titles to 
                which have not been extinguished, including 
                rights-of-way running through such allotments.
          (2)[(4)] Alaska native land.--The term ``Alaska 
        Native land'' means (A) land conveyed or to be conveyed 
        pursuant to the Alaska Native Claims Settlement Act (43 
        U.S.C. 1600 et seq.) [43 U.S.C.A. Sec. 1601 et seq.], 
        including any land reconveyed under section 14(c)(3) of 
        that Act (43 U.S.C. 1613(c)(3)), and (B) land conveyed 
        pursuant to the Act of November 2, 1966 (16 U.S.C. 1151 
        et seq.; commonly known as the ``Fur Seal Act of 
        1966'').
          (6)[(5)] Indian tribal government.--The term ``Indian 
        tribal government'' means the governing body of any 
        Indian tribe, band, nation, pueblo, or other organized 
        group or community which is recognized as eligible for 
        the special programs and services provided by the 
        United States to Indians because of their status as 
        Indians.
          (1)[(6)] Alaska native entity.--The term ``Alaska 
        Native entity'' includes native corporations 
        established pursuant to the Alaska Native Claims 
        Settlement Act [43 U.S.C.A. Sec. 1601 et seq.] and any 
        Alaska Native village or municipal entity which owns 
        Alaska Native land.
          (7) Open dump.--The term ``open dump'' means any 
        facility or site where solid waste is disposed of which 
        is not a sanitary landfill which meets the criteria 
        promulgated under section 4004 of the Solid Waste 
        Disposal Act (42 U.S.C. 6944) and which is not a 
        facility for disposal of hazardous waste.
          (8) Postclosure maintenance.--The term ``postclosure 
        maintenance'' means any activity undertaken at a closed 
        solid waste management facility on Indian land or on 
        Alaska Native land to maintain the integrity of 
        containment features, monitor compliance with 
        applicable performance standards, or remedy any 
        situation or occurrence that violates regulations 
        promulgated pursuant to subtitle D of the Solid Waste 
        Disposal Act (42 U.S.C. 6941 et seq.).
          (9) Service.--The term ``Service'' means the Indian 
        Health Service.
          (10) Solid waste.--The term ``solid waste'' has the 
        meaning provided that term by section 1004(27) of the 
        Solid Waste Disposal Act (42 U.S.C. 6903) and any 
        regulations promulgated thereunder.

Sec. 3903. Inventory of open dumps

    (a) Study and Inventory.--
    Not later than 12 months after October 22, 1994, the 
[Director] Assistant Secretary shall conduct a study and 
inventory of open dumps on Indian lands and Alaska Native 
lands. The inventory shall list the geographic location of all 
open dumps, an evaluation of the contents of each dump, and an 
assessment of the relative severity of the threat to public 
health and the environment posed by each dump. Such assessment 
shall be carried out cooperatively with the Administrator of 
the Environmental Protection Agency. The Director shall obtain 
the concurrence of the Administrator in the determination of 
relative severity made by any such assessment.
    (b) Annual Reports.--
    Upon completion of the study and inventory under subsection 
(a) of this section, the [Director] Assistant Secretary shall 
report to the Congress, and update such report annually--
    (c) 10-Year Plan.--
    The [Director] Assistant Secretary shall develop and begin 
implementation of a 10-year plan to address solid waste 
disposal needs on Indian lands and Alaska Native lands. This 
10-year plan shall identify--

Sec. 3904. Authority of [the Director of the Indian Health Service] 
                    Assistant Secretary for Indian Health

    (a) Reservation Inventory.--
          (1) Upon request by an Indian tribal government or 
        Alaska Native entity, the [Director] Assistant 
        Secretary shall--
                  (B) determine the relative severity of the 
                threat to public health and the environment 
                posed by each dump based on information 
                available to the [Director] Assistant Secretary 
                and the Indian tribal government or Alaska 
                Native entity unless the [Director] Assistant 
                Secretary, in consultation with the Indian 
                tribal government or Alaska Native entity, 
                determines that additional actions such as soil 
                testing or water monitoring would be 
                appropriate in the circumstances; and
          (2) The inventory and evaluation authorized under 
        paragraph (1)(A) shall be carried out cooperatively 
        with the Administrator of the Environmental Protection 
        Agency. The [Director] Assistant Secretary shall obtain 
        the concurrence of the Administrator in the 
        determination of relative severity made under paragraph 
        (1)(B).
    (b) Assistance.--
    Upon completion of the activities required to be performed 
pursuant to subsection (a) of this section, the [Director] 
Assistant Secretary shall, subject to subsection (c) of this 
section, provide financial and technical assistance to the 
Indian tribal government or Alaska Native entity to carry out 
this activities necessary to--
    (c) Conditions.--
    All assistance provided pursuant to subsection (b) of this 
section shall be made available on a site-specific basis in 
accordance with priorities developed by the [Director] 
Assistant Secretary. Priorities on specific Indian lands or 
Alaska Native lands shall be developed in consultation with the 
Indian tribal government or Alaska Native entity. The 
priorities shall take into account the relative severity of the 
threat to public health and the environment posed by each open 
dump and the availability of funds necessary for closure and 
postclosure maintenance.

Sec. 3905. Contact authority

    (a) Authority of [Director] Assistant Secretary.--
    To the maximum extent feasible, the [Director] Assistant 
Secretary shall carry out duties under this chapter through 
contracts, compacts, or memoranda of agreement with Indian 
tribal governments or Alaska Native entities pursuant to the 
Indian Self-Determination and Education Assistance Act (25 
U.S.C. 450 et seq.), section 2004a of Title 42, or section 1632 
of this title.
    (b) Cooperative Agreements.--
    The [Director] Assistant Secretary is authorized, for 
purposes of carrying out the duties of the [Director] Assistant 
Secretary under this chapter, to contract with or enter into 
such cooperative agreements with such other Federal agencies as 
is considered necessary to provide cost-sharing for closure and 
postclosure activities, to obtain necessary technical and 
financial assistance and expertise, and for such other purposes 
as the [Director] Assistant Secretary considers necessary.

Sec. 3906. Tribal demonstration project

    (a) In General.--
    The [Director] Assistant Secretary may establish and carry 
out a program providing for demonstration projects involving 
open dumps on Indian land or Alaska Native land. It shall be 
the purpose of such project to determine if there are unique 
cost factors involved in the cleanup and maintenance of open 
dumps on such land, and the extent to which advanced closure 
planning is necessary. Under the program, the [Director] 
Assistant Secretary is authorized to select no less than three 
Indian tribal governments or Alaska Native entities to 
participate in such demonstration projects.
    (b) Criteria.--
    Criteria established by the [Director] Assistant Secretary 
for the selection and participation of an Indian tribal 
government or Alaska Native entity in the demonstration project 
shall provide that in order to be eligible to participate, an 
Indian tribal government or Alaska Native entity must--

Sec. 3907. Authorization of appropriations

    (b) Coordination.--
    The activities required to be performed by the [Director] 
Assistant Secretary under this chapter shall be coordinated 
with activities related to solid waste and sanitation 
facilities funded pursuant to other authorizations.

Sec. 3908. Disclaimers

    (a) Authority of [Director] Assistant Secretary.--
    Nothing in this chapter shall be construed to alter, 
diminish, repeal, or supersede any authority conferred on the 
[Director] Assistant Secretary pursuant to section 1632 of this 
title, and section 2004a of Title 42.
                              ----------                              


                       UNITED STATES PUBLIC LAWS


                     110TH CONGRESS--SECOND SESSION


               PL 100-297, APRIL 28, 1988, 102 STAT. 130


                            25 USC 2001 NOTE


Sec. 5504. Administrative Provisions

    (d) Federal Agency Cooperation and Assistance.--
          (2) The Commissioner of the Administration for Native 
        Americans of the Department of Health and Human 
        Services and the [Director of the Indian Health 
        Service] Assistant Secretary for Indian Health of the 
        Department of Health and Human Services are authorized 
        to detail personnel to the Task Force, upon request, to 
        enable the Task Force to carry out its functions under 
        this part.
                              ----------                              


                      UNITED STATES CODE ANNOTATED


                            TITLE 29--LABOR

CHAPTER 16--VOCATIONAL REHABILITATION AND OTHER REHABILITATION SERVICES


                  Subchapter II--Research and Training


Sec. 763. Interagency Committee

    (a) Establishment; Membership; Meetings.--
          (1) In order to promote coordination and cooperation 
        among Federal departments and agencies conducting 
        rehabilitation research programs, including programs 
        relating to assistive technology research and research 
        that incorporates the principles of universal design, 
        there is established within the Federal Government an 
        Interagency Committee on Disability Research 
        (hereinafter in this section referred to as the 
        ``Committee''), chaired by the Director and comprised 
        of such members as the President may designate, 
        including the following (or their designees): the 
        Director, the Commissioner of theRehabilitation 
Services Administration, the Assistant Secretary for Special Education 
and Rehabilitative Services, the Secretary of Education, the Secretary 
of Veterans Affairs, the Director of the National Institutes of Health, 
the Director of the National Institute of Mental Health, the 
Administrator of the National Aeronautics and Space Administration, the 
Secretary of Transportation, the Assistant Secretary of the Interior 
for Indian Affairs, the [Director of the Indian Health Service] 
Assistant Secretary for Indian Health, and the Director of the National 
Science Foundation.
                              ----------                              


                      UNITED STATES CODE ANNOTATED


               TITLE 33--NAVIGATION AND NAVIGABLE WATERS

           CHAPTER 26--WATER POLLUTION PREVENTION AND CONTROL


                    Subchapter V--General Provisions


Sec. 1377. Indian Tribes

    (b) Assessment of Sewage Treatment Needs; Report.--
    The Administrator, in cooperation with the [Director of the 
Indian Health Service] Assistant Secretary for Indian Health, 
shall assess the need for sewage treatment works to serve 
Indian tribes, the degree to which such needs will be met 
through funds allotted to States under section 1285 of this 
title and priority lists under section 1296 of this title, and 
any obstacles which prevent such needs from being met. Not 
later than one year after February 4, 1987, the Administrator 
shall submit a report to Congress on the assessment under this 
subsection, along with recommendations specifying (1) how the 
Administrator intends to provide assistance to Indian tribes to 
develop waste treatment management plans and to construct 
treatment works under this chapter, and (2) methods by which 
the participation in and administration of programs under this 
chapter by Indian tribes can be maximized.
    (e) Treatment as States.--
    The Administrator is authorized to treat an Indian tribe as 
a State for purposes of subchapter II of this chapter and 
sections 1254, 1256, 1313, 1315, 1318, 1319, 1324, 1329, 1341, 
1342, 1344, and 1346 of this title to the degree necessary to 
carry out the objectives of this section, but only if-- . . . 
Such treatment as a State may include the direct provision of 
funds reserved under subsection (c) of this section to the 
governing bodies of Indian tribes, and the determination of 
priorities by Indian tribes, where not determined by the 
Administrator in cooperation with the [Director of the Indian 
Health Service] Assistant Secretary for Indian Health, is 
authorized to make grants under subchapter II of this chapter 
in an amount not to exceed 100 percent of the cost of a project

           *       *       *       *       *       *       *

                              ----------                              


                      UNITED STATES CODE ANNOTATED


                TITLE 42--THE PUBLIC HEALTH AND WELFARE

                   CHAPTER 6A--PUBLIC HEALTH SERVICE


                Subchapter II--General Powers and Duties


                   PART B--FEDERAL-STATE COOPERATION


Sec. 247b-14. Oral Health Promotion and Disease Prevention

    (b) Community Water Fluoridation.--
          (1) In general.--
          The Secretary, acting through the Director of the 
        Centers for Disease Control and Prevention and in 
        collaboration with the [Director of the Indian Health 
        Service] Assistant Secretary for Indian Health, shall 
        establish a demonstration project that is designed to 
        assist rural water systems in successfully implementing 
        the water fluoridation guidelines of the Centers for 
        Disease Control and Prevention that are entitled 
        ``Engineering and Administrative Recommendations for 
        Water Fluoridation, 1995'' (referred to in this 
        subsection as the ``EARWF'').
          (2) Requirements.--
                  (A) Collaboration.--
                  In collaborating under paragraph (1), [the 
                Directors referred to in such paragraph] the 
                Director of the Centers for Disease Control and 
                Prevention and the Assistant Secretary for 
                Indian Health shall ensure that technical 
                assistance and training are provided to tribal 
                programs located in each of the 12 areas of the 
                Indian Health Service. The [Director of the 
                Indian Health Service] Assistant Secretary for 
                Indian Health shall provide coordination and 
                administrative support to tribes under this 
                section.
                              ----------                              


                      UNITED STATES CODE ANNOTATED


                TITLE 42--THE PUBLIC HEALTH AND WELFARE

                   CHAPTER 6A--PUBLIC HEALTH SERVICE


              Subchapter III--National Research Institutes


  PART C--SPECIFIC PROVISIONS RESPECTING NATIONAL RESEARCH INSTITUTES


                  Subpart 1--National Cancer Institute


Sec. 285a-9. Grants for Education, Prevention, and Early Detection of 
                    Radiogenic Cancers and Diseases

    (b) In General.--
    The Secretary, acting through the Administrator of the 
Health Resources and Services Administration in consultation 
with the Director of the National Institutes of Health and the 
[Director of the Indian Health Service] Assistant Secretary for 
Indian Health, may make competitive grants to any entity for 
the purpose of carrying out programs to--

           *       *       *       *       *       *       *

                              ----------                              


                      UNITED STATES CODE ANNOTATED


                TITLE 42--THE PUBLIC HEALTH AND WELFARE

                   CHAPTER 6A--PUBLIC HEALTH SERVICE


             Subchapter XII--Safety of Public Water Systems


                       PART E--GENERAL PROVISIONS


Sec. 300j-12. State Revolving Loan Funds

    (i) Indian Tribes.--
          (2) Use of funds.--
          Funds reserved pursuant to paragraph (1) shall be 
        used to address the most significant threats to public 
        health associated with public water systems that serve 
        Indian Tribes, as determined by the Administrator in 
        consultation with the [Director of the Indian Health 
        Service] Assistant Secretary for Indian Health and 
        Indian Tribes.
          (4) Needs assessment.--
          The Administrator, in consultation with the [Director 
        of the Indian Health Service] Assistant Secretary for 
        Indian Health and Indian Tribes, shall, in accordance 
        with a schedule that is consistent with the needs 
        surveys conducted pursuant to subsection (h) of this 
        section, prepare surveys and assess the needs of 
        drinking water treatment facilities to serve Indian 
        Tribes, including an evaluation of the public water 
        systems that pose the most significant threats to 
        public health.
                              ----------                              


                      UNITED STATES CODE ANNOTATED


                TITLE 42--THE PUBLIC HEALTH AND WELFARE

                CHAPTER 34--ECONOMY OPPORTUNITY PROGRAM


               Subchapter VIII--Native American Programs


Sec. 2991b-2. Establishment of Administration for Native Americans

    (d) Intra-Departmental Council on Native American 
Affairs.--
          (1) There is established in the Office of the 
        Secretary of the Intra-Departmental Council on Native 
        American Affairs. The Commissioner shall be the 
        chairperson of such Council and shall advise the 
        Secretary on all matters affecting Native Americans 
        that involve the Department. The [Director of the 
        Indian Health Service] Assistant Secretary for Indian 
        Health shall serve as vice chairperson of the Council.
                              ----------                              


                       UNITED STATES PUBLIC LAWS


                     105TH CONGRESS--FIRST SESSION


             PL 105-143, DECEMBER 15, 1997, 111 STAT. 2652


               MICHIGAN INDIAN LAND CLAIMS SETTLEMENT ACT


Sec. 203. Limitation

    (b) Consideration.--
    In any case in which the Secretary, acting through the 
[Director of the Indian Health Service] Assistant Secretary for 
Indian Health, is required to select from more that 1 
application for a contract or compact described in subsection 
(a), in awarding the contract or compact, the Secretary shall 
take into consideration--

           *       *       *       *       *       *       *

                              ----------                              


                       UNITED STATES PUBLIC LAWS


                     91ST CONGRESS--SECOND SESSION


              PL 91-557, DECEMBER 17, 1970, 84 STAT. 1485


Sec. 9.

    Nothing in this Act shall preclude the Soboba Band of 
Mission Indians and the Soboba Indian Reservation from being 
provided with sanitation facilities and services under the 
authority of section 7 of the Act of August 5, 1954 (68 Stat. 
674), as amended by the Act of July 31, 1959 (73 Stat. 267).
                              ----------                              


                      UNITED STATES CODE ANNOTATED


                TITLE 42--THE PUBLIC HEALTH AND WELFARE

                       CHAPTER 7--SOCIAL SECURITY


   Susbchapter XIX--Grants to States for Medical Assistance Programs


Sec. 1396j. Indian Health [Service facilities] Programs

    (a) Eligibility for [r]Reimbursement for [m]Medical 
[a]Assistance.--
    [A facility of t]The Indian Health Service and an Indian 
Tribe, Tribal Organization, or an urban Indian Organization 
[(including a hospital, nursing facility, or any other type of 
facility which provides services of a type otherwise covered 
under the State plan), whether operated by such Service or by 
an Indian tribe or tribal organization] (as [those] such terms 
are defined in section 4 of the Indian Health Care Improvement 
Act[1603 of Title 25]), shall be eligible for reimbursement for 
medical assistance provided under a State plan or under waiver 
authority with respect to items and services furnished by the Indian 
Health Service, Indian Tribe, Tribal Organization, or Urban Indian 
Organization if the furnishing of such services [and for so long as it] 
meets all [of] the conditions and requirements which are applicable 
generally to the furnishing of items and services [such facilities] 
under this title and under such plan or waiver authority [subchapter].
    [(b) Facilities deemed to meet requirements upon submission 
of acceptable plan for achieving compliance
    [Notwithstanding subsection (a) of this section, a facility 
of the Indian Health Service (including a hospital, nursing 
facility, or any other type of facility which provides services 
of a type otherwise covered under the State plan) which does 
not meet all the conditions and requirements of this title 
which are applicable generally to such facility, but which 
submits to the Secretary within six months after September 30, 
1976, an acceptable plan for achieving compliance with such 
conditions and requirements, shall be deemed to meet such 
conditions and requirements (and to be eligible for 
reimbursement under this subchapter), without regard to the 
extent of its actual compliance with such conditions and 
requirements, during the first twelve months in which such plan 
is submitted.]
    (b)[(c)] Authority to Enter Into Agreements [Agreement to 
reimburse State agency for providing care and services].--
    The Secretary may [is authorized to] enter into an 
agreement[s] with a [the] State [agency] for the purpose of 
reimbursing the State [such agency] for medical assistance 
[health care and services] provided by the [in] Indian Health 
Service, an Indian Tribe, Tribal Organizations, or an Urban 
Indian Organization (as so defined), directly, through 
referral, or under contracts or other arrangements between the 
Indian Health Service, an Indian Tribe, Tribal Organization, or 
an Urban Indian Organization and another health care provider 
[facilities] to Indians who are eligible for medical assistance 
under the State plan or under waiver authority.
    (c)[(d)] Direct B[b]illing.--F[f]or Payment Under Medicare, 
Medicaid, and Other Third Party Payors
    For provisions relating to the authority of certain Indian 
tribes, tribal organizations, and Alaska Native health 
organizations to elect to directly bill for, and receive 
payment for, health care services provided by a hospital or 
clinic of such tribes or organizations and for which payment 
may be made under this subchapter, see section 1645 of Title 
25.
                              ----------                              


                      UNITED STATES CODE ANNOTATED


                TITLE 42--THE PUBLIC HEALTH AND WELFARE

                       CHAPTER 7--SOCIAL SECURITY


       Subchapter XXI--State Children's Health Insurance Program


Sec. 1397ee. Payments to States

    (c) Limitation on Certain Payments for Certain 
Expenditures.--
          (6) Prevention of duplicative payments.--
                  (B) Other Federal governmental programs.--
                  Except as provided in subparagraph (A) or (B) 
                of subsection (a)(1) or any other provision of 
                law, no payment shall be made to a State under 
                this section for expenditures for child health 
                assistance provided for a targeted low-income 
                child under its plan to the extent that payment 
                has been made or can reasonably be expected to 
                be made promptly (as determined in accordance 
                with regulations) under any other federally 
                operated or financed health care insurance 
                program, [other than an insurance program 
                operated or financed by the Indian Health 
                Service,] other than a health program operated 
                or financed by the Indian Health Service or by 
                an Indian Tribe, Tribal Organization, or Urban 
                Indian Organization (as such terms are defined 
                in section 4 of the Indian Health Care 
                Improvement Act) as identified by the 
                Secretary. For purposes of this paragraph, 
                rules similar to the rules for overpayments 
                under section 1396b(d)(2) of this title shall 
                apply.

                                  
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