[Senate Report 109-278]
[From the U.S. Government Publishing Office]



                                                       Calendar No. 469
109th Congress                                                   Report
                                 SENATE
 2d Session                                                     109-278

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



 
  MEDICARE, MEDICAID, AND SCHIP INDIAN HEALTH CARE IMPROVEMENT ACT OF 
                                  2006

                                _______
                                

                 July 12, 2006.--Ordered to be printed

                                _______
                                

  Mr. Grassley, from the Committee on Finance, submitted the following

                              R E P O R T

                         [To accompany S. 3524]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Finance, having had under consideration an 
original bill (S. 3524), to amend titles XVIII, XIX, and XXI of 
the Social Security Act to improve health care provided to 
Indians under the Medicare, Medicaid, and State Children's 
Health Insurance Programs, and for other purposes, reports 
favorably thereon and recommends that the bill do pass.

                         I. LEGISLATIVE HISTORY

    The Finance Committee passed S. 3524, the Medicare, 
Medicaid, and SCHIP Indian Health Care Improvement Act of 2006 
on June 8, 2006. S. 3524 is an original bill encompassing 
provisions of S. 1057, the ``Indian Health Care Improvement 
Act'' (IHCIA), that fall into the Finance Committee's 
jurisdiction--i.e., issues related to Medicare, Medicaid, and 
SCHIP. The IHCIA (S. 1057) was reported favorably out of the 
Senate Indian Affairs Committee on March 16, 2006. It is the 
intention of the Committee that the provisions of S. 3524 be 
incorporated into S. 1057 when it is considered by the full 
Senate.
    S. 1057 would authorize the appropriation of such sums as 
necessary through 2015 for the Indian Health Care Improvement 
Act, the primary authorizing legislation for the Indian Health 
Service (IHS). The bill also contains specific authorizations 
for a program to encourage Indians to pursue careers related to 
behavioral health, a demonstration project to provide suicide 
prevention services, a commission on Indian health care, and 
administrative costs for a new nonprofit corporation. In 
addition, the bill also would affect direct spending, primarily 
through provisions affecting the Medicaid program. CBO 
estimates that implementing S. 1057 would cost $2.6 billion in 
2007 and $30.4 billion over the period 2007-2016.

                    II. SECTION-BY-SECTION ANALYSIS


               SECTION 1. SHORT TITLE; TABLE OF CONTENTS

Current law

    No provision.

Description of provision

    This act may be cited as the ``Medicare, Medicaid, and 
SCHIP Indian Health Care Improvement Act of 2006.''

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

(a) Medicaid

Current law

    A facility of the Indian Health Service (IHS) (including 
hospitals, nursing facilities or any other type of facility 
that provides services that are coverable under the Medicaid 
State plan), whether operated by the IHS or by an Indian tribe 
(IT) or a tribal organization (TO), as defined in Section 4 of 
the Indian Health Care Improvement Act (IHCIA), is eligible for 
Medicaid reimbursement under the State Medicaid plan, if and 
for so long as it meets all of the conditions and requirements 
generally applicable to such facilities under Title XIX of the 
Social Security Act (SSA).
    Section 1911(b) of the SSA provides that if a facility of 
the IHS which does not meet all of the conditions and 
requirements of Title XIX which are generally applicable to 
such a facility, that submits to the Secretary of Health and 
Human Services (HHS), an acceptable plan for achieving 
compliance with such conditions and requirements, must be 
deemed to meet such conditions and requirements, and to be 
eligible for Medicaid reimbursement, without regard to the 
extent of its actual compliance with such conditions and 
requirements, during the first 12 months after the month in 
which such plan is submitted.
    Under Section 1911(c) of the SSA, the Secretary of HHS is 
authorized to enter into agreements with the State Medicaid 
agency for purpose of reimbursing such agency for Medicaid 
services provided in IHS facilities to Indians who are eligible 
for Medicaid under the State Medicaid plan.
    The Medicaid statute (Section 1911(d) of the SSA) points to 
Section 405 of the IHCIA, which describes the provisions 
relating to the authority of certain ITs, TOs, and Alaska 
Native health organizations to elect to directly bill for, and 
receive payment for, health care services covered by Medicaid 
and provided by a hospital or clinic of such entities.

Description of provision

    These provisions would completely replace their 
counterparts (described above) in current law.
    The provision would require that the IHS and ITs, TOs and 
Urban Indian Organizations (UIOs) be reimbursed for Medicaid 
items and services provided under the State plan or a waiver, 
if the provision of those services meets all the conditions and 
requirements generally applicable to the delivery of such care.
    A facility of the IHS or an IT, TO, or UIO which is 
eligible for Medicaid reimbursement, but which does not meet 
all of the conditions and requirements of Medicaid under the 
State plan or a waiver which are generally applicable to such a 
facility, must make such improvements as are necessary to 
achieve or maintain compliance in accordance with a plan 
submitted to and accepted by the Secretary for meeting such 
conditions and requirements. The Secretary may deem a facility 
compliant for an initial twelve month period as under current 
law.
    The provision would also allow the Secretary of HHS to 
enter into an agreement with a State for the purpose of 
reimbursing that State for Medicaid services provided by the 
IHS, an IT, TO or UIO, directly, through referral, or under 
contracts or otherarrangements between these entities and 
another health care provider to Indians eligible for Medicaid under the 
State Medicaid plan or a waiver.
    The provision would also provide a cross-reference to a 
special fund into which are placed payments to which a facility 
of the Indian Health Service is entitled under Medicaid. These 
provisions describe the authority of the Secretary to place 
Medicaid payments for which IHS facilities are eligible into a 
special fund, requires the Secretary to ensure that 100 percent 
of the payment for which facilities are eligible are paid out, 
and further requires facilities to use any amounts in excess of 
the amount necessary to achieve or maintain compliance for the 
purposes of improving IHS facilities. These requirements are 
outlined in subparagraphs (A) and (B) of Section 401(c)(1) of 
the IHCIA.
    The provision would also point to Section 401(d) of the 
IHCIA for rules relating to the authority of a Tribal Health 
Program (THP) or UIO to elect to directly bill for, and receive 
payment for, health care items and services reimbursable under 
Medicaid.
    Finally, the bill would point to Section 4 of the IHCIA for 
definitions of the following terms: Indian Health Program, 
Indian Tribe, Tribal Health Program, Tribal Organization, and 
Urban Indian Organization.

(b) Medicare

Current law

    The Social Security Act generally prohibits payment to any 
Federal agency for services which would otherwise be covered 
under Medicare. However, Section 1880 of the Act provides an 
exception for IHS facilities. Section 1880(a) provides an 
exception for hospitals and skilled nursing facilities (SNF) 
whether operated by the Service or by an Indian tribe or tribal 
organization if and for so long as the entity meets the 
conditions and requirements for payments generally applicable 
to such facilities under Medicare. Section 1880(b) established 
a temporary provision for submission of an acceptable 
compliance plan for a hospital or SNF not meeting all of these 
conditions and requirements in 1976. Section 1880(c) specifies 
that payments to which any hospital or SNF of the IHS is 
otherwise entitled is to be placed in a special fund to be held 
by the Secretary. The Secretary is to use the payments (to the 
extent provided in appropriations Acts) exclusively for the 
purpose of making improvements in hospitals and SNFs which may 
be needed to achieve compliance with Medicare conditions and 
requirements. The provision would cease to apply when the 
Secretary determined and certified that substantially all the 
hospitals and SNFs of the IHS are in compliance. Section 
1880(d) specifies that the annual report of the Secretary 
(required by the Indian Health Care Improvement Act) is to 
include a detailed statement of the status of hospitals and 
SNFs in terms of their compliance and of their progress toward 
achievement of such compliance.
    Section 1880(e) extends payment, effective July 1, 2001, to 
certain services furnished in hospitals and ambulatory care 
clinics (whether provider-based or free-standing) operated by 
the IHS or by an Indian tribe (IT) or tribal organization (TO). 
The specified services are those provided by physicians, 
nonphysician practitioners, and physical and occupational 
therapists and which are paid for under the physician fee 
schedule. Effective for the 5-year period beginning January 1, 
2005, the authority is extended to all services for which 
payment may be made under Medicare Part B.
    Section 1880(f) provides a cross-reference to Section 405 
of the IHCIA 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 
payments for health care services provided by a hospital or 
clinic of such tribe or organization.

Description of provision

    The provision would rewrite Section 1880 of the Social 
Security Act. New Section 1880(a) would specify that the Indian 
Health Service, and an Indian Tribe, Tribal Organization, or an 
Urban Indian Organization would be eligible for Medicare 
payments for services furnished by such entities, provided such 
services met all the conditions and requirements generally 
applicable to the furnishing of such services under Medicare. 
Application of the provision would be subject to the revised 
Section 1880(e).
    New Section 1880(b) would require facilities of the Indian 
Health Service, or an Indian Tribe, Tribal Organization, or an 
Urban Indian Organization, which are eligible for reimbursement 
under Medicare, but which do not meet all of the conditions and 
requirements generally applicable to such facilities, to make 
improvements. The improvements would be in accordance with a 
plan submitted to and accepted by the Secretary for achieving 
or maintaining compliance with such conditions and 
requirements. The Secretary may deem a facility compliant for 
initial 12-month period as under current law.
    New Section 1880(c) would provide a cross reference to the 
special fund established under Section 401(c)(1) of the IHCIA 
for provisions relating to the authority of the Secretary to 
place payments to which a facility of the Indian Health Service 
is entitled under Medicare in a special fund. It would provide 
a further cross reference to section 401(c)(1) (A) and (B) of 
the IHCIA, which require the Secretary to ensure that 100 
percent of the payment for which facilities are eligible are 
paid out, and further requires facilities to use any amounts in 
excess of the amount necessary to achieve or maintain 
compliance for the purposes of improving IHS facilities.
    New Section 1880(d) would provide a cross reference to 
Section 401(d) of the IHCIA for provisions relating to the 
authority of a Tribal Health Program (THP) or Urban Indian 
Organization to elect to directly bill for, and receive payment 
for, health care items and services provided by such program or 
organization for which payment would be made under Medicare.
    The provision would make a conforming change to the 
existing Section 1880(e) to specify that Section 401(c)(1) of 
the IHCIA, as well as new Section 1880(c), would not apply to 
payments made under Section 1880(e).
    New Section 1880(f) would specify that the following terms 
have the meanings given to these terms in Section 4 of the 
IHCIA: Indian Health Program, Indian Tribe, Service Unit, 
Tribal Health Program, Tribal Organization, and Urban Indian 
Organization.

(c) Application to SCHIP

Current law

    No provision.

Description of provision

    This provision would apply all but one subsection of these 
Medicaid provisions to the SCHIP program, including: (1) the 
provision regarding eligibility of Indian entities to receive 
reimbursement (as defined in the new Section 1911(a)); (2) the 
provision regarding compliance with conditions and requirements 
(as defined in the new Section 1911(b)); (3) the provision 
regarding the authority of the Secretary of HHS to enter into 
agreements with States to provide Medicaid reimbursement to 
Indian entities (as defined in the new Section 1911(c)); (4) 
the provision regarding direct billing (as defined in the new 
Section 1911(e); and (5) the provision defining terms referring 
to Indian entities (as defined in the new Section 1911(f)). The 
provision regarding the special fund for improving IHS 
facilities (as defined in the new Section 1911(d)) would not 
apply to SCHIP.

For informational purposes only, background on provision contained in 
        amendment of S. 1057

    Section 401, which revises Section 401 of the Indian Health 
Care Improvement Act Amendments of 2005, as reported (S. 1057), 
would amend parts of Sections 401, 402, and 405 of the Indian 
Health Care Improvement Act. Section 401(a), which is identical 
to Section 401(a) of S. 1057, would expand to SCHIP the 
prohibition in IHCIA on any Medicare and Medicaid payments 
received by a hospital or skilled nursing facility (SNF) of IHS 
(whether operated by the IHS, a tribe, or tribal organization 
under a Indian Self-Determination Act contract) for services 
provided to eligible Indians from being considered in 
determining appropriations for health care and services to 
Indians. Section 401(a) would also expand the prohibition to 
cover any such payments received by an Urban Indian 
Organization, and to cover payments for any services provided, 
not just services from hospitals or SNFs.
    Section 401(b), which is identical to Section 401(b) of S. 
1057, would include an amendment to the IHCIA that nothing in 
the law authorizes the Secretary to provideservices to Indian 
Medicare and Medicaid or SCHIP beneficiaries in preference to those 
without such coverage.
    Section 401(c), which is nearly identical to Section 401(c) 
of S. 1057, would expand current law, which directs that IHS 
put all Medicaid payments to IHS facilities in a special fund 
to be held by the Secretary, and to require that reimbursements 
from Medicare also be deposited in the special fund. It would 
expand allowable uses of the special fund to cover improvements 
in all IHS programs to comply with conditions of Medicare (as 
well as Medicaid) programs, and would require that reimbursed 
amounts in excess of the amount necessary to meet such 
compliance conditions be used, subject to the consultation with 
tribes being served by the IHS service unit, for reducing the 
health resource deficiencies of the tribes. It would increase 
to 100 percent (from 80 percent) the proportion of any SSA 
reimbursement (to which an IHS service unit is entitled) that 
the Secretary must ensure goes to that service unit. Section 
401(c) would further provide that the requirement for placement 
of reimbursements in the special fund shall not apply to Tribal 
Health Programs, as well as Urban Indian Organizations (added 
by this amendment to S. 1057), that elect under Section 401(d) 
to receive reimbursements directly, but would allow no payments 
from the special fund during the period the Tribal Health 
Program or Urban Indian Organization elects to receive 
reimbursements directly. Tribal Health Programs are defined in 
Section 4 of S. 1057, as reported, as tribes or tribal 
organizations that operate health programs under a self-
determination funding agreement.
    Section 401(d) would amend provisions in current law 
authorizing the option of direct billing of Medicare, Medicaid, 
and third-party payors for health care services by Tribal 
Health Programs operating hospitals and clinics. It would 
revise S. 1057 to make that bill's provisions parallel to 
similar provisions in Section 2 of the proposed ``Medicare, 
Medicaid, and SCHIP Indian Health Care Improvement Act of 
2006,'' as reported (see new Sections 1911(c) and 1880(c)); it 
would drop S. 1057 language allowing direct billing for SCHIP 
services; it would drop language that only direct billing 
participants who also receive self-determination or urban 
Indian health program funding need to give IHS their provider 
enrollment numbers or other identifiers; it retains a current 
law provision (dropped in S. 1057) requiring that amounts paid 
to a Tribal Health Program or Urban Indian Organization under a 
Social Security Act program be subject to the auditing 
requirements applicable to that program's payments; and it 
would add language stating nothing in the auditing provision 
may be construed as limiting the application of Medicare, 
Medicaid, and SCHIP auditing requirements; it would add a 
requirement that IHS provide the CMS Administrator with 
provider enrollment numbers and enrollment data regarding 
patients served by the Service (and, to the extent such data 
are available, by Tribal Health Programs and Urban Indian 
Organizations) and other information the CMS Administrator may 
require if the tribe receives funding from the Service under 
the Indian Self-Determination and Education Assistance Act or 
an Urban Program 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; and it 
would add a provision authorizing the Secretary to terminate a 
Tribal Health Program's or Urban Indian Organization's 
participation in the direct billing program if the Secretary 
determined that the program or organization failed to comply 
with the direct billing program's requirements, if the 
Secretary provided advance notice and a reasonable opportunity 
to correct the noncompliance.
    Section 401(d) would expand the current direct billing 
program to include Urban Indian Organizations, would require 
that reimbursements be used for compliance improvements and 
additional health care, health facilities, and other broad 
health-care-related purposes, but would delete the current law 
prioritization of spending on compliance improvements. It would 
delete provisions directing the Secretary to monitor 
participating hospitals and clinics and require annual reports 
from them, and it would delete participation criteria and 
application requirements. As in current law, participants in 
the direct billing program may withdraw from the program under 
the same conditions as retrocession from a contracted program 
occurs under the Indian Self-Determination Act (although all 
cost accounting and billing authority must be returned to the 
Secretary when the withdrawal is accepted), and the Secretary 
through IHS, and with assistance from the CMS Administrator, is 
directed to examine and implement any administrative changes 
that would facilitate direct billing, including agreements with 
States.
    New Section 401(e) would add a cross-reference to Sections 
1880, 1911, and 2107(e)(1)(D) of the Social Security Act for 
provisions related to Section 401(c) and (d).

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

Current law

    No provision in Social Security Act.
    Section 404(a) of the IHCIA requires the Secretary to make 
grants or enter into contracts with Tribal Organizations for 
establishing and administering programs on or near Federal 
Indian reservations and trust areas and in or near Alaska 
Native villages. The purpose of the programs is to assist 
individual Indians to enroll in Medicare, apply for Medicaid 
and pay monthly premiums for coverage due to financial need of 
such individuals. Section 404(b) of the IHCIA directs the 
Secretary, through the IHS, to set conditions for any grant or 
contract. The conditions include, but are not limited to: (1) 
determining the Indian population that is, or could be, served 
by Medicare and Medicaid; (2) assisting individual Indians to 
become familiar with and use benefits; (3) providing 
transportation to Indians to the appropriate offices to enroll 
or apply for medical assistance; and (4) developing and 
implementing both an income schedule to determine premium 
payment levels for coverage of needy individuals and methods to 
improve Indian participation in Medicare and Medicaid. Section 
404(c) of the IHCIA authorizes the Secretary, acting through 
the IHS, to enter into agreements with tribes, Tribal 
Organizations, and Urban Indian Organizations to receive and 
process applications for medical assistance under Medicaid and 
benefits under Medicare at facilities administered by the IHS, 
or by a tribe, Tribal Organization or Urban Indian Organization 
under the Indian Self-Determination Act.

Description of provision

    The provision would add a new Section 1139 to the Social 
Security Act (replacing the current Section 1139 provision 
dealing with an expired National Commission on Children).
    The new Section 1139(a) would encourage States to take 
steps to provide for enrollment of Indians residing on or near 
a reservation in Medicaid and SCHIP. The steps could include 
outreach efforts such as: outstationing of eligibility workers; 
entering into agreements with the Indian Health Service, Indian 
Tribes, Tribal Organizations, and Urban Indian Organizations to 
provide outreach; education regarding eligibility and benefits; 
and translation services. Nothing could be construed as 
affecting arrangements between States and the Indian Health 
Service, Indian Tribes, Tribal Organizations, and Urban Indian 
Organizations for them to conduct administrative activities 
under Medicaid or SCHIP.
    The new Section 1139(b) would require the Secretary, acting 
through CMS, to take such steps as necessary to facilitate 
cooperation with and agreements between States, and the IHS, 
Indian Tribes, Tribal Organizations, or Urban Indian 
Organizations relating to the provision of benefits to Indians 
under Medicare, Medicaid, and SCHIP.
    The New Section 1139(c) would specify that the following 
terms have the meanings given to these terms in Section 4 of 
the Indian Health Care Improvement Act: Indian Tribe, Indian 
Health Program, Tribal Organization, and Urban Indian 
Organization.

For informational purposes only, background on provision contained in 
        amendment of S. 1057

    Section 402, which revises Section 402 of S. 1057, as 
reported, would amend Section 404 of the IHCIA, concerning 
assistance to Indians to enroll in Medicare, Medicaid, and 
SCHIP. Section 402(a) would expand current law--which requires 
the Secretary to make grants or contracts with tribal 
organizations for programs on or near reservations, trust 
areas, and Alaska Native villages to assist individual Indians 
to enroll in Medicare and apply for Medicaid [and to pay 
monthly premiums due to such Indians' financial need--to cover 
enrollment in SCHIP, make tribes eligible recipients, and allow 
the tribes or tribal organizations to determine financial need 
based on a schedule of income levels developed or implemented 
by the tribes]. Section 402(a) would limit appropriations for 
such grants and contracts to those authorized under Title IV of 
the IHCIA. Section 402(a) would expand current law and S. 1057 
to cover payment not only of premiums but also of cost sharing, 
but unlike current law and S. 1057 would limit such payment to 
those programs for which the charging of premiums and cost 
sharing is not prohibited. New Section 402(f) would define 
``premium'' as any enrollment fee or similarcharge and ``cost 
sharing'' as any deduction, deductible, copayment, coinsurance, or 
similar charge.
    Section 402(b) would continue current law requiring the 
Secretary, acting through the IHS, to set conditions for grants 
or contracts under Section 402. The conditions would include 
requirements that the tribe or tribal organization determine 
the population eligible for Medicare, Medicaid, or SCHIP 
benefits, educate Indians about benefits available under the 
programs, provide transportation for individual Indians to the 
appropriate offices for enrollment or application for benefits, 
and develop and implement methods of improving Indian 
participation in these programs. New Section 402(c), identical 
to Section 402(e) in S. 1057, would apply this section's 
provisions on agreements to Urban Indian Organizations for the 
populations that they serve, and would require that agreements 
with the Organizations include requirements that are consistent 
with those in subsection (b), appropriate to urban Indians and 
such Organizations, and necessary to effect the purposes of 
Section 402.
    New Section 402(d) would require the Secretary, acting 
through CMS, to facilitate cooperation with and agreements 
between the States and IHS, tribes, tribal organizations, and 
Urban Indian Organizations, but would revise S. 1057 by 
limiting the cooperation and agreements to the provision of 
health care to Indians under Medicare, Medicaid, or SCHIP.
    New Section 402(e) would drop the authorization in Section 
402(c) of current law, and in S. 1057, for tribal processing of 
Indians' applications for Medicare and Medicaid, and drop S. 
1057's extension of that authority to SCHIP. Section 402(e) 
instead adds a cross-reference to new Section 1139(a) of the 
Social Security Act added by the proposed ``Medicare, Medicaid, 
and SCHIP Indian Health Care Improvement Act of 2006.''

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

(a) Nonapplication of 10-percent limit on outreach and certain other 
        expenditures

Current law

    Title XXI of the Social Security Act provides States with 
annual Federal SCHIP allotments based on a formula set in law. 
State SCHIP payments are matched by the Federal Government at 
an enhanced rate that builds on the base rate applicable to 
Medicaid. The SCHIP statute also specifies that Federal SCHIP 
funds can be used for SCHIP health insurance coverage, called 
child health assistance that meets certain requirements. States 
may also provide benefits to SCHIP children, called targeted 
low-income children, through enrollment in Medicaid. Apart from 
these benefit payments, SCHIP payments for four other specific 
health care activities can be made, including: (1) other child 
health assistance for targeted low-income children; (2) health 
services initiatives to improve the health of targeted low-
income children and other low-income children; (3) outreach 
activities; and (4) other reasonable administrative costs. For 
a given fiscal year, SCHIP statute specifies that payments for 
these four other specific health care activities cannot exceed 
10 percent of the total amount of expenditures for benefits 
(excluding payments for services rendered during periods of 
presumptive eligibility under Medicaid) and other specific 
health care activities combined.
            Description of provision
    The provision would exclude from the 10 percent cap on 
SCHIP payments (for the four specific health care activities 
described above) the following activities: (1) expenditures for 
outreach activities to families of Indian children likely to be 
eligible for separate SCHIP programs or Medicaid expansions 
under SCHIP authority, or under related waivers, and (2) 
related informing and enrollment assistance activities for 
Indian children under such programs, expansions, or waivers, 
including such activities conducted under grants, contracts, or 
agreements entered into under the new grant program delineated 
in the Section 1139(a) of this Act (described in Section 3 
above).

(b) Assurance of payments to Indian health care providers for child 
        health assistance

Current law

    Among other assurances, the State SCHIP plan must include a 
description of the procedures to be used to ensure the 
provision of child health assistance to targeted low-income 
children in the State who are Indians (as defined in Section 
4(c) of the IHCIA).

Description of provision

    The provision would strike the reference to Section 4(c) of 
the IHCIA, and would expand this assurance to include how the 
State will ensure that payments are made to IHPs and UIOs 
providing SCHIP benefits in the State.

(c) Inclusion of other Indian financed health care programs in 
        exemption from prohibition on certain payments

Current law

    To prevent duplicative payments, the SCHIP statute 
specifies that no payments shall be made to a State for 
expenditures for child health assistance when that payment has 
been made or can reasonably be expected to be made promptly 
under any other federally operated or financed health care 
insurance program, other than an insurance program operated or 
financed by the IHS, as identified by the Secretary.

Description of provision

    This provision would add ITs, TOs and UIOs, to the 
exemption from the prohibition on SCHIP payments in the same 
manner currently applicable to the IHS.

(d) Satisfaction of Medicaid documentation requirements

Current law

    Under the Deficit Reduction Act of 2005 (DRA), States are 
prohibited from receiving Federal Medicaid reimbursement for an 
individual who has not provided satisfactory documentary 
evidence of citizenship or nationality. Satisfactory evidence 
includes one document (from a list specified in the law) that 
provides reliable documentation of identity and proof of U.S. 
citizenship or nationality. Satisfactory evidence also includes 
one document (from a list specified in the law) that provides 
proof of U.S. citizenship or nationality and one document (also 
from a list specified in the law) that provides reliable 
documentation of identity.
    Section 6036(a)(2) of DRA specifies that the requirements 
do not apply to an alien who is (1) eligible for Medicaid and 
is entitled to or enrolled for Medicare benefits, (2) eligible 
for Medicaid on the basis of receiving Supplemental Security 
Income (SSI) benefits, or (3) eligible for Medicaid on such 
other basis as the Secretary of HHS may specify that 
satisfactory evidence had been previously presented.
    The provision applies to initial determinations and to 
redeterminations of eligibility for Medicaid made on or after 
July 1, 2006.

Description of provision

    For the purpose of establishing Medicaid eligibility, this 
provision would add ``a document issued by a federally-
recognized Indian tribe evidencing membership or enrollment in, 
or affiliation with, such tribe'' to the list of accepted 
documents that provide reliable documentation of identity and 
proof of U.S. citizenship or nationality. The provision would 
also make a technical correction to a reference to a 
subparagraph in Section 1903(i) of the Medicaid statute.
    With respect to those federally-recognized Indian tribes 
located within States having an international border whose 
membership includes individuals who are not citizens of the 
United States, the Secretary shall, after consulting with such 
tribes, issue regulations authorizing the presentation of such 
other forms of documentation (including tribal documentation, 
if appropriate) that the Secretary determines to be 
satisfactory documentary evidence of citizenship or nationality 
for purposes of satisfying the requirement of this subsection.
    During the period that begins on July 1, 2006, and ends on 
the effective date of final regulations issued under subclause 
(II) of section 1903(x)(3)(B)(v) of the Social Security Act (42 
U.S.C. 1396b(x)(3)(B)(v)) (as added by paragraph (1)), an 
individual who is a member of a federally-recognized Indian 
tribe described in subclause (II) of thatsection who presents a 
document described in subclause (I) of such section that is issued by 
such Indian tribe, shall be deemed to have presented satisfactory 
evidence of citizenship or nationality for purposes of satisfying the 
requirement of subsection (x) of section 1903 of such Act.

(e) Definitions

Current law

    Under SCHIP statute, definitions of specific terms are 
provided, including for example, ``child,'' ``creditable health 
coverage,'' ``low-income,'' etc.

Description of provision

    For SCHIP purposes, the provision would specify that the 
terms ``Indian,'' ``Indian Health Program,'' ``Indian Tribe,'' 
``Tribal Organization,'' and ``Urban Indian Organization'' have 
the same meanings given those terms in Section 4 of the IHCIA.

For informational purposes only, background on provision contained in 
        amendment of S. 1057

    Section 410, which replaces Section 410 of S. 1057, as 
reported, would add a new Section 410 to the Indian Health Care 
Improvement Act, concerning expenditures for SCHIP outreach to 
Indians and SCHIP payments to Indian health programs. Section 
410(1) would add a cross-reference to Sections 2105(c)(2) and 
1139 of the Social Security Act, as amended by the proposed 
``Medicare, Medicaid, and SCHIP Indian Health Care Improvement 
Act of 2006,'' concerning outreach to families whose Indian 
children may be eligible for SCHIP. Section 410(2) adds a 
cross-reference to Sections 2101(b)(3)(D) and 2105(c)(6)(B) of 
the Social Security Act, as amended, concerning targeting of 
SCHIP assistance to low-income Indian children and SCHIP 
payments to Indian Health Programs to include IHS, tribal, and 
tribal organizations' health programs) and Urban Indian 
Organizations.

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

(a) Premiums and cost sharing protection under Medicaid

Current law

    Under Medicaid, premiums and enrollment fees are generally 
prohibited for most beneficiaries classified as categorically 
needy. Nominal premiums and enrollment fees specified in 
regulations can be collected from persons classified as 
medically needy, certain families qualifying for transitional 
medical assistance, and pregnant women and infants with income 
over 150 percent of the Federal poverty level. Premiums and 
enrollment fees can exceed these nominal amounts for persons 
classified as workers with disabilities (up to other specified 
limits), and for individuals covered under Section 1115 
waivers.
    Service-related cost-sharing (e.g., deductibles, 
copayments, and coinsurance) is prohibited for children under 
18, for pregnant women, and for selected services (i.e., in a 
hospital, long-term care facility or other institution if 
spend-down is required; for hospice care; for emergency 
services; and for family planning services and supplies) 
provided to individuals classified as categorically needy or 
medically needy. For most other groups and services, nominal 
cost-sharing amounts are allowed as specified in regulations. 
For individuals classified as workers with disabilities, and 
those covered under Section 1115 waivers, service-related cost-
sharing can exceed these nominal amounts.
    Finally, the DRA of 2005 added a new State option for 
alternative premiums and cost-sharing, effective as of March 
31, 2006. Generally, this new option provides States with 
additional flexibility to apply premiums and service related 
cost-sharing for certain Medicaid subgroups. Special cost-
sharing rules apply to prescription drugs and to non-emergency 
services delivered in an emergency room.

Description of provision

    The provision would add a new subsection specifying that no 
enrollment fee, premium or similar charge, and no deduction, 
co-payment, cost-sharing, or similar charge shall be imposed 
against an Indian who receives Medicaid-coverable services or 
items directly from the IHS, an IT, TO, or UIO, or through 
referral under the contract health service. In addition, 
Medicaid payments due to the IHS, an IT, TO, or UIO, or to a 
health care provider through referral under the contract health 
service for providing services to a Medicaid-eligible Indian, 
could not be reduced by the amount of any enrollment fee, 
premium or similar charge, or by the amount of any cost-sharing 
or similar charge that would otherwise be due from an Indian, 
if such charges were permitted.
    Nothing in this provision shall be construed as restricting 
the application of any other limitations on the imposition of 
premiums or cost-sharing that may apply to a Medicaid-enrolled 
Indian.
    This provision would stipulate that the terms ``contract 
health service,'' ``Indian,'' ``Indian Tribe,'' ``Tribal 
Organization,'' and ``Urban Indian Organization'' have the 
meanings given those terms in Section 4 of the IHCIA.
    Finally, the provision would stipulate that these 
provisions would not be superseded by the new State option for 
alternative premiums and cost-sharing added by the DRA of 2005.

(b) Treatment of certain property for Medicaid and SCHIP eligibility

Current law

    The Federal Medicaid statute defines more than 50 
eligibility pathways. For some pathways, States are required to 
apply an assets test. For other pathways, assets tests are a 
State option. When assets tests apply, some pathways give 
States flexibility to define specific assets that are to be 
counted and which can be disregarded. For other pathways, 
primarily for people qualifying on the basis of having a 
disability or who are elderly, assets tests are required. 
Assets under those tests are specifically defined in the 
Supplemental Security Income (SSI) statute in Title XVI of the 
Social Security Act. Under SSI law, several types of assets are 
excluded, including: (1) any land held in trust by the United 
States for a member of a federally-recognized tribe, or any 
land held by an individual Indian or tribe and which can only 
be sold, transferred, or otherwise disposed of with the 
approval of other individuals, his or her tribe, or an agency 
of the Federal Government; and (2) certain distributions 
(including land or an interest in land) received by an 
individual Alaska Native or descendant of an Alaska Native from 
an Alaska Native Regional and Village Corporation pursuant to 
the Alaska Native Claims Settlement Act. All other property, 
except for the applicant's primary residence, is required to be 
counted.
    There is no similar provision in current SCHIP law.

Description of provision

    Notwithstanding any other Federal or State law, the 
provision would prohibit consideration of four different 
classes of property in determining Medicaid eligibility. These 
classes include: (1) property located on a reservation, 
including any federally-recognized Indian Tribe's reservation, 
Pueblo, or Colony, including former reservations in Oklahoma, 
Alaska Native regions established by the Alaska Native Claims 
Settlement Act (ANCSA), and Indian allotments on or near a 
reservation as designated and approved by the Bureau of Indian 
Affairs; (2) for any federally-recognized Tribe not described 
in the first class, property located within the most recent 
boundaries of a prior Federal reservation; (3) ownership 
interests in rents, leases, royalties, or usage rights related 
to natural resources, including extraction of natural resources 
or harvesting of timber, other plants and plant products, 
animals, fish, and shellfish, resulting from the exercise of 
federally protected rights; and (4) ownership interest in or 
usage rights to items not covered in the previous classes that 
have unique religious, spiritual, traditional, or cultural 
significance or rights that support subsistence or a 
traditional life style according to applicable tribal law or 
custom.
    The provision would also apply this new language to SCHIP 
in the same manner in which it applies to Medicaid.

(c) Continuation of current law protections of certain Indian property 
        from Medicaid estate recovery

Current law

    Under Medicaid, the Secretary is allowed to specify 
standards for a State hardship waiver of asset criteria for 
Medicaid estate recovery purposes.

Description of provision

    The provision would provide that certain income, resources, 
and property would remain exempt from Medicaid estate recovery 
if they were exempted under Section 1917(b)(3) of the Social 
Security Act (allowing the Secretary to specify standards for a 
State hardship waiver of asset criteria) under instructions 
regarding Indian tribes and Alaskan Native Villages as of April 
1, 2003. The provision would also allow the Secretary to 
provide for additional estate recovery exemptions for Indians 
under Medicaid.

For informational purposes only, background on provision contained in 
        amendment of S. 1057

    Section 412, which replaces Section 412 of S. 1057, as 
reported, would add a new Section 412 to the Indian Health Care 
Improvement Act, concerning Indian cost sharing and treatment 
of Indian property under Medicaid and SCHIP. Section 412(1) 
adds a cross-reference to Sections 1916(j) and 1916A(a)(1) of 
the Social Security Act, as amended by proposed ``Medicare, 
Medicaid, and SCHIP Health Care Improvement Act of 2006,'' 
concerning Medicaid premiums and cost sharing protections for 
health care provided Indians by Indian Health Programs, either 
directly or through referral. Section 412(2) adds a cross-
reference to Sections 1902(e)(13) and 2107(e)(1)(B) of the 
Social Security Act, as amended by the bill, for rules 
concerning treatment of certain kinds of Indian property in 
determining Medicaid eligibility. Section 412(3) adds a cross-
reference to Section 1917(b)(3)(B) of the Social Security Act, 
as amended by the bill, concerning protection of certain types 
of Indian property from Medicaid estate recovery provisions.
    Section 412(a) of S. 1057, as reported, would exempt 
Indians from Medicaid, SCHIP, and IHS deductibles, coinsurance, 
and copayments, and would prohibit reducing the Medicaid or 
SCHIP payment or reimbursement due to IHS, a tribe, a tribal 
organization, or an Urban Indian Organization by the amount of 
the deductible, co-payment, or coinsurance that would have been 
due from the Indian. Section 412(b) would exempt eligible 
Indians from Medicaid or SCHIP premiums, enrollment fees, or 
similar charges. Section 412(c) would exclude certain 
reservation, Alaskan, trust, restricted, cultural, and 
subsistence Indian property, and rights-based natural resource 
ownership interests, from the Medicaid eligibility 
determinations. Section 412(d) would provide similar 
protections of Indian property from Medicaid estate recovery.

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

Current law

    No provision.

Description of provision

    The provision would add an additional subsection to New 
Section 1139, as added by Section 3 of this bill. New Section 
1139(c) would require a Federal health care program to accept 
an entity that is operated by the IHS, an Indian Tribe, Tribal 
Organization, or Urban Indian Organization as a provider 
eligible to receive payment or reimbursement on the same basis 
as any other provider qualified to participate as a provider 
under the program. This requirement would apply if the entity 
met generally applicable State or other requirements for 
participation as a provider of health care services under the 
program. Any requirement that an entity be licensed or 
recognized under State or local law where the entity is located 
would be deemed to be met in the case of an entity operated by 
the IHS, Indian Tribe, Tribal Organization, or Urban Indian 
Organization, if the entity met all applicable standards for 
such licensure or recognition. Under certain circumstances, the 
fact that a health care professional employed by the entity did 
not have licensure under the State or local law where the 
entity was located would not be taken into account for purposes 
of determining whether the entity met the standards. 
Specifically, the absence of such licensure would not be taken 
into account if the professional was licensed in another State. 
This would be in accordance with Section 221 of the IHCIA.
    The provision would prohibit payments under Federal health 
care programs for services to Indians to any entity operated by 
the IHS, Indian Tribe, Tribal Organization, or Urban Indian 
Organization, if the entity was excluded from participation in 
any Federal health care program. The prohibition would also 
apply if the entity's State license was either under suspension 
or revoked. Further, no individual excluded from participation 
in any Federal health care program or whose State license was 
under suspension or revoked would be eligible to receive 
payment or reimbursement under any Federal health care program 
for services furnished to an Indian.
    The provision would define the term Federal health care 
program as the term is defined under Section 1128B(f) of the 
Social Security Act, except that the exclusion of the Federal 
employees health benefits program would not apply. Section 
1128B(f) specifies that the term means any plan or program that 
provides health benefits directly, through insurance or 
otherwise, which is funded directly in whole or in part by the 
U.S. Government. Section 1128B(f) specifies that the term also 
includes the following State health care programs; Medicaid, 
any program receiving funds under the maternal and child health 
services block grant program or from an allotment to a State 
under such program, any program receiving funds under the 
social services block grant program or from an allotment to a 
State under such program, or a State child health plan approved 
under the SCHIP program.

For informational purposes only, background on provision contained in 
        amendment of S. 1057

    Section 408, which revises Section 408 of the Indian Health 
Care Improvement Act Amendments of 2005, as reported (S. 1057), 
would add a new Section 408 to the Indian Health Care 
Improvement Act, concerning eligibility of IHS and Indian 
entities to become providers and receive payments under Federal 
health care programs. Section 408 would divide the same section 
in S. 1057, as reported, into two subsections. Section 408(a) 
would require that a Federal health care program accept an 
entity operated by IHS, a tribe, tribal organization, or Urban 
Indian Organizations as a provider eligible to receive payments 
or reimbursements on the same basis as other qualified 
providers if the entity meets generally applicable State or 
other requirements. Section 408(b) would deem entities operated 
by IHS, a tribe, tribal organization, or Organization to have 
met State or local licensing or recognition requirements if the 
entities met all applicable licensing or recognition standards, 
regardless of whether an entity has obtained the license or 
other documentation, and regardless of whether a health care 
professional employed by the entity has a State or local 
license as long as the professional is licensed in another 
State. A new subsection, Section 408(c), would add a cross-
reference to Section 1139(c) of the Social Security Act, as 
added by the bill, regarding nondiscrimination against IHS, 
tribal, tribal organization, or Urban Indian Organization 
providers.

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

Current law

    There are no provisions in current Medicaid or SCHIP 
statutes regarding a Tribal Technical Advisory Group (T-TAG) 
within the Centers for Medicare and Medicaid Services (CMS), 
the Federal agency that oversees the Medicare, Medicaid and 
SCHIP programs. Current Federal guidance requires States 
submitting waivers under Section 1915 or 1115 of the Social 
Security Act to engage in the following activities related to 
consultation with Tribal Governments in their State: (1) notify 
in writing all federally-recognized Tribal Governments 
maintaining a primary office in the State at least 60 days 
before submitting the waiver or renewal of the State's intent 
to submit such waiver or renewal to CMS; (2) ensure the notice 
to the tribal Government describes the purpose of the waiver or 
renewal and anticipates the impact on tribal members; (3) 
ensure the notice also describes a method for appropriate 
Tribal representatives to provide official written comments and 
questions in a timeframe allowing State analysis and 
consideration and discussion between the States and the Tribes 
responding to the notice; (4) provide Tribal Governments with a 
reasonable period of at least 30 days in which to respond to 
the notice; and (5) provide an opportunity for an in-person 
meeting with Tribal representatives to discuss issues.

Description of provision

    The provision would require the Secretary to maintain 
within CMS a Tribal TAG, previously established in accordance 
with requirements of a charter dated September 30, 2003. The 
provision also would require that the TAG include a 
representative of the UIOs and IHS. The UIO representative 
would be deemed an elected official of a tribal government for 
the purposes of applying Section 204(b) of the Unfunded 
Mandates Reform Act of 1995, which exempts elected tribal 
officials from the Federal Advisory Committee Act for certain 
meetings with Federal officials.
    The provision would also require certain States to 
establish a process for obtaining advice on a regular, on-going 
basis from designees of IHPs and UIOs on matters relating to 
the application of Medicaid law likely to have a direct effect 
on those entities. Applicable States would include those in 
which the IHS operates or funds health programs, or in which 
one or more IHPs or UIOs provide health care for which Medicaid 
can be billed. This process would include seeking advice prior 
to submission of State Medicaid plan amendments, waiver 
requests or proposed demonstrations likely to directly affect 
Indians, IHPs, or UIOs. This process could include appointment 
of an advisory panel and of a designee of IHPs and UIOs to the 
Medicaid medical care advisory committee advising the State on 
its State Medicaid plan.
    The provision would also apply this new language to SCHIP 
in the same manner in which it applies to Medicaid.
    Finally, the provision would prohibit construing these 
amendments as superseding existing advisory committees, working 
groups, guidance, or other advisory procedures established by 
the Secretary or any State with respect to the provision of 
health care to Indians.

For informational purposes only, background on provision contained in 
        amendment of S. 1057

    Section 409, which replaces Section 409 of the Indian 
Health Care Improvement Act Amendments of 2005, as reported (S. 
1057), would add a new Section 409 to the Indian Health Care 
Improvement Act, making a cross-reference to Section 1139(d) of 
the Social Security Act, as amended by the bill, concerning 
consultation with Indian Health Programs and Urban Indian 
Organizations on the Medicare, Medicaid, and SCHIP programs.
    Section 409(a) of S. 1057, as reported, would require the 
Secretary to maintain the Tribal Technical Advisory Group 
established under a CMS charter and to include an Urban Indian 
Organization representative. Section 409(b) would require a 
State to establish a process to seek advice on relevant 
Medicaid matters from Indian Health Programs and Urban Indian 
Organizations; the process would include solicitation of advice 
on proposed Medicaid plan amendments, waiver requests, and 
demonstration projects, creation of an advisory committee, or 
appointment of an Indian designee to the State's medical care 
advisory committee. Section 409(c) would direct that nothing in 
Section 409 superseded any existing advisory procedures, 
guidance, committees, or groups established by the Secretary or 
a State.

           SECTION 8. SANCTIONS UNDER THE SOCIAL SECURITY ACT

Current law

    The Social Security Act establishes sanctions for certain 
prohibited activities in connection with Medicare, Medicaid, 
and SCHIP. Under certain circumstances, primarily in cases of 
access issues, waivers may be requested.
    Section 1128B(b) of the Social Security Act authorizes 
criminal penalties for anyone knowingly and willfully 
soliciting or receiving remuneration in return for: (1) 
referring any individual for services for which Federal health 
program payment may be made; or (2) purchasing, leasing, or 
ordering or arranging for purchasing, leasing, or ordering any 
good, facility, service, or item for which payment may be made 
under a Federal health care program.

Description of provision

    The provision would add an additional subsection to New 
Section 1139, as added by Section 3, and amended by Sections 6 
and 7, of this bill. New Section 1139(e) would establish a 
process for requesting waivers of sanctions imposed against a 
health care provider under Title XI of the Social Security Act 
(General Administrative provisions). The process would apply 
insofar as the provider provided services through an Indian 
Health Program. The administrator of the affected Indian Health 
Program would petition the Secretary directly for a waiver.
    The provision would specify that certain transactions 
involving Indian Health Care Programs would not be deemed 
remuneration for purposes of applying Section 1128B(b) of the 
Social Security Act. Safe harbors would be established for 
certain transfers between or among an Indian Health Program, 
Indian Tribe, Tribal Organization, or Urban Indian Organization 
that were made for the purpose of providing necessary health 
care items and services to patients served by such Program, 
Tribe, or Organization. Covered transfers would be services in 
connection with the collection, transport, analysis, and/or 
interpretation of diagnostic specimens or test data, inventory 
or supplies, staff, or a waiver of all or part of premiums or 
cost sharing.
    Safe harbors would also be established for certain 
transfers between an Indian Health Program, Indian Tribe, 
Tribal Organization, or Urban Indian Organization and any 
patient served or eligible for services from such entity, 
including any patient served or eligible for service pursuant 
to Section 807 of the IHCIA. A safe harbor would only exist if 
one of the following three criteria was met. First, the 
transfer was for the purpose of providing transportation for 
the patient for the provision of necessary health care items or 
services; and the provision of such services could not be 
advertised, nor considered an incentive of which the value is 
disproportionately large in relationship to the value of the 
care service. Second, the transfer was for the purpose of 
providing housing to the patient (including a pregnant patient) 
and immediate family members or an escort necessary to assuring 
the timely provision of health services to the patient; and the 
provision of such services could not be advertised, nor 
considered an incentive of which the value is 
disproportionately large in relationship to the value of the 
care service. The third permissible type of transfer would be 
for the purpose of paying premiums or cost sharing on behalf of 
a patient; the payment could not be subject to conditions other 
than those under a contract for the delivery of contract health 
services.
    A safe harbor would be established for a transfer 
negotiated as part of a contract entered into between Indian 
Health Program, Indian Tribe, Tribal Organization, Urban Indian 
Organization, or the Indian Health Service, and a contract care 
provider, provided that the transfer is not tied to the volume 
or value of referrals or other business generated by the 
parties, and any such transfer be limited to the fair market 
value of the services provided.
    Additional safe harbors would be established for other 
transfers involving an Indian Health Program, Indian Tribe, 
Tribal Organization, or Urban Indian Organization or patient 
served or eligible for service from such an entity. Such 
additional safe harbors would occur only if the Secretary, in 
consultation with the Attorney General, determined that they 
were appropriate given the special circumstances of Indian 
Health Programs, Indian Tribes, Tribal Organizations, or Urban 
Indian Organizations and of the patients served by such 
entities.

For informational purposes only, background on provision contained in 
        amendment of S. 1057

    Section 411, which replaces Section 411 of the Indian 
Health Care Improvement Act Amendments of 2005, as reported (S. 
1057), would add a new Section 411 to the Indian Health Care 
Improvement Act, making a cross-reference to Section 1139(e) of 
the Social Security Act, as amended by this bill, concerning 
sanctions against providers of services through Indian Health 
Programs.
    Section 411(a) of S. 1057, as reported, would allow an 
Indian Health Program to request from the Secretary a waiver of 
sanctions imposed against one of its health care provider if 
the State does not seek the waiver after the Program's request. 
Section 411(b) would specify that certain exchanges of items or 
services of value are not to be treated as remuneration, in 
violation of anti-kickback provisions in Section 1128B of the 
Social Security Act, if they are exchanged between or among 
Indian Health Programs and Urban Indian Organizations, or if 
they are exchanged between tribes, tribal organizations, 
Programs, or Organizations and patients served or eligible to 
be served and are for health-related transportation, housing, 
cost sharing, or low-value items or services provided as 
incentives, or if the exchanges are between or among programs, 
organizations, tribes, or tribal organizations and meet 
standards deemed appropriate by the Secretary (in consultation 
with the Attorney General) that take into account the special 
circumstances of the programs, organizations, tribes, tribal 
organizations, and their patients.

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

(a) In general (for Medicaid)

Current law

    Section 1903(m)(1) of Title XIX defines: (1) the term 
Medicaid managed care organization, (2) requirements regarding 
accessibility of services for Medicaid managed care 
organizations (MCO) beneficiaries vis-a-vis non-MCO Medicaid 
beneficiaries within the area served by the MCO; (3) solvency 
standards in general and specific to different types of 
organizations; and (4) the duties and functions of the 
Secretary with respect to the status of an organization as a 
Medicaid MCO.
    Section 1902(w) of Title XIX specifies requirements for 
advance directives applicable to Medicaid managed care 
organizations, institutional providers (e.g., hospitals, 
nursing facilities), providers of home health care or personal 
care services, and hospice programs.
    Title XIX contains a number of additional provisions 
regarding managed care under Medicaid. Section 1932(a)(5) 
specifies rules regarding the provision of information about 
managed care to beneficiaries and potential enrollees. Such 
information must be in an easily understood form, and must 
address the following topics: (1) who providers are and where 
they are located, (2) enrollee rights and responsibilities, (3) 
grievance and appeal procedures, (4) covered items and 
services, (5) comparative information for available MCOs 
regarding benefits, cost-sharing, service area and quality and 
performance, and (6) information on benefits not covered under 
managed care arrangements. In addition, Section 1932(d)(2)(B) 
requires managed care entities to distribute marketing 
materials to their entire service areas.
    Sections 1903(m) and 1932 provide cross-referencing 
definitions for the term ``Medicaid managed care 
organization.''
    In general, Federally Qualified Health Centers (FQHCs) are 
paid on a per visit basis, using a prospective payment system 
that takes into account costs incurred and changes in the scope 
of services provided. Per visit payment rates are also adjusted 
annually by the Medicare Economic Index applicable to primary 
care services. When an FQHC is a participating provider with a 
Medicaid managed care entity (MCE), the State must make 
supplemental payments to the center in an amount equal to any 
difference between the rate paid by the MCE and the per visit 
amount determined under the prospective payment system under 
Section 1902(bb)(5). In addition, some Indian Health Care 
providers currently receive an encounter rate payment under a 
Memorandum of Agreement between CMS and the Indian Health 
Service effective July 11, 1996.
    Title XIX includes specific provisions limiting mandatory 
enrollment of Indians in Medicaid MCEs in Section 
1932(a)(2)(C).

Description of provision

    The provision would require that Indians enrolled in a non-
Indian Medicaid managed care entity (MCE) with an IHP or UIO 
participating as a primary care provider within the MCE's 
network be allowed to choose such an IHP or UIO as their 
primary care provider when the Indian is otherwise eligible to 
receive services from such a provider and the IHP or UIO has 
the capacity to provide primary care services to that Indian. 
Contracts between the State and such MCEs must reflect this 
requirement, and Medicaid payments to the MCE are conditional 
on meeting this requirement.
    The provision would stipulate that contracts with Medicaid 
MCEs must require those MCEs with a significant percentage of 
Indian enrollees (as determined by the Secretary), to meet 
other requirements as a condition of receiving Medicaid 
payments. These conditions include: (1) such MCEs must 
demonstrate that the number of participating Indian health care 
providers is sufficient to ensure timely access to covered 
Medicaid managed care services for those enrollees who are 
eligible to receive services from such providers; or (2) such 
MCEs must agree to pay non-participating Indian health care 
providers (except for non-participating FQHCs and non-FQHC 
Indian Health providers that have a Memorandum of Agreement 
between CMS and the Indian Health Service) at a rate equal to 
the rate negotiated between such entity and the provider 
involved, or, if such a rate has not been negotiated, at a rate 
that is not less than the level and amount of payment which the 
MCE would make for services rendered by a participating non-
Indian health care provider. Special Medicaid payment rules 
would apply to an Indian health care provider that is an FQHC 
that does not participate with a Medicaid managed care entity. 
Payments to such non-participating FQHCs would be at rates 
otherwise applicable to FQHCs that are participating providers 
with the MCE. These provisions do not waive the existing 
requirement that States make supplemental payments due to a 
FQHC for services rendered under a contract with an MCE to 
bring the payment rate up to the rate owed under the 
prospective payment system. Indian health providers that are 
not federally qualified health care centers, and that elect to 
receive payment under Title XIX as an Indian Health provider 
under the Memorandum of Agreement between CMS and the Indian 
Health Service effective July 11, 1996 will also be eligible to 
receive a supplemental payment for that service in the same 
manner as a federally qualified health center under 
1902(bb)(5).
    In addition, such MCEs must agree to make prompt payment 
(in accordance with rules applicable to MCEs) to participating 
Indian health care providers or, in the case of a non-
participating Indian health care provider (excluding non-
participating FQHCs), the second condition listed above must 
apply. The provision also stipulates that the submission of a 
claim or other documentation for services by the IHP or UIO 
(consistent with Section 403(h) of the IHCIA) would be deemed 
to satisfy any requirement for an enrollee to submit a claim or 
other documentation. The provision would also require that as a 
condition of payment for covered services, the IHP or UIO 
comply with all generally applicable Medicaid requirements to 
the extent that these requirements do not conflict with other 
requirements or prohibitions imposed on the IHP or UIO through 
other statutes. The IHP or UIO shall only need to comply with 
those generally applicable requirements of a managed care 
entity as a condition of payment that are necessary for the 
entity's compliance with the State plan such as those related 
to care management, quality assurance and utilization 
management.
    The provision would also prohibit waiving requirements 
relating to assurances that payments are consistent with 
efficiency, economy and quality.
    Under this provision States must offer to enter into an 
agreement with Indian Medicaid MCEs to serve eligible Indians 
if: (1) the State elects to provide services through Medicaid 
MCEs under its Medicaid managed care program, and (2) an Indian 
health care provider that is funded in whole or in part by the 
IHS, or a consortium composed of one or more tribes, TOs, or 
UIOs as well as the IHS (if applicable), has established an 
Indian Medicaid MCE in the State that meets all generally 
applicable standards required for such an entity under the 
State's Medicaid managed care program.
    The provision also contains a number of special rules that 
would be applicable to Indian MCEs. With respect to enrollment, 
Indian Medicaid MCEs could restrict enrollment to Indians and 
to members of specific tribes in the same manner as IHPs may 
restrict the delivery of services to such Indians and tribal 
members. Also, among Medicaid MCEs, the State could not limit 
the choice of an Indian only to Indian Medicaid MCEs, and the 
provision does not allow States to be more restrictive in the 
choice of MCEs offered to Indian versus non-Indian 
beneficiaries. Also, if enrollment of an Indian in a Medicaid 
MCE is mandatory, the provision would require such States to 
enroll Indians who are not otherwise enrolled in an MCE to be 
enrolled in an Indian Medicaid MCE. Such enrollment must be 
consistent with the Indian's eligibility for enrollment with 
such an entity based on the service area and capacity of the 
entity, and must take into consideration maintaining existing 
provider-individual relationships or relationships with 
providers that have traditionally served Medicaid 
beneficiaries. Finally, under procedures specified by the 
Secretary, the provision would also require States to grant 
requests by Indians enrolled with a non-Indian Medicaid MCE to 
switch to an Indian Medicaid MCE.
    Additional special rules would apply to flexibility in 
application of solvency standards for Indian Medicaid MCEs. The 
provision would specify that such entities must demonstrate, to 
the satisfaction of the Secretary (rather than the State), that 
they have made adequate provision against the risk of 
insolvency, and as with other Medicaid MCEs, must assure that 
individuals eligible for benefits are in no case held liable 
for debts of the entity in case of the organization's 
insolvency. The provision would also deem Indian Medicaid MCEs 
to be public entities, and thus, exempt these MCEs from 
requirements to meet solvency standards established by the 
State for private health maintenance organizations, and from 
requirements that such MCEs be licensed or certified by the 
State as risk-bearing entities. The provision would continue to 
apply other rules in Section 1903(m)(1) to Indian Medicaid 
MCEs.
    With respect to special rules for Indian Medicaid MCEs and 
advance directives, the provision would allow the Secretary to 
modify or waive requirements related to maintenance of written 
policies and procedures for such directives, if the Secretary 
finds that these requirements are not an appropriate or 
effective way to communicate such information to Indians.
    With respect to special rules for Indian Medicaid MCEs and 
flexibility in information and marketing, the provision would 
allow the Secretary to modify requirements defined in Section 
1932(a)(5) to ensure that information provided to enrollees and 
potential enrollees of Indian Medicaid MCEs is delivered in a 
culturally appropriate and understandable manner that clearly 
communicates individual rights, protections, and benefits. 
Also, in the case of an Indian Medicaid MCE that distributes 
appropriate materials only to those Indians potentially 
eligible to enroll with the entity in its service area, the 
requirements of Section 1932(d)(2)(B), with respect to 
distribution of marketing material to an entire service area, 
must be deemed to be satisfied.
    In general, the provision specifies that under a Medicaid 
managed care program, if a health care provider is required to 
have medical malpractice insurance as a condition of 
contracting with a Medicaid MCE, an Indian health care provider 
that is either (1) a FQHC that is covered under the Federal 
Tort Claims Act; (2) a provider that delivers services pursuant 
to a contract under the Indian Self-Determination and Education 
Assistance Act, would be deemed to satisfy such a requirement; 
or (3) the Indian Health Service, which is covered under the 
Federal Tort Claims Act.
    Finally, the provision provides definitions for several 
terms. An ``Indian health care provider'' means an IHP or UIO. 
The terms ``Indian,'' ``Indian Health Program,'' ``Service,'' 
``Tribe, Tribal Organization,'' and ``Urban Indian 
Organization'' all have the meanings given such terms in 
Section 4 of the IHCIA. The term ``Indian Medicaid managed care 
entity'' means a MCE that is controlled by the IHP, a Tribe, 
TO, or UIO, or a consortium, which may be composed of one or 
more tribes, TOs, or UIOs, and which also may include the IHS, 
for which the term ``control'' means the possession, whether 
direct or indirect, of the power to direct or cause the 
direction of the management and policies of the organization 
through membership, board representation, or an ownership 
interest equal to or greater than 50.1 percent. The term ``non-
Indian Medicaid managed care entity'' means a MCE that is not 
an Indian Medicaid MCE. The term ``covered Medicaid managed 
care services'' means the items and services that are within 
the scope of benefits available under the contract between the 
entity and the State involved. The term ``Medicaid managed care 
program'' means a program under Sections 1903(m) and 1932, and 
includes a managed care program operating under a waiver under 
Sections 1915(b) or 1115 or otherwise.

(b) Application to SCHIP

Current law

    Under Title XIX, Section 1932(a)(2)(C) stipulates the rules 
regarding Indian enrollment in Medicaid managed care. A State 
may not require an Indian (as defined in Section 4(c) of the 
IHCIA) to enroll in a managed care entity unless the entity is 
one of the following (and only if such entity is participating 
under the plan): (1) the IHS, (2) an IHP operated by an Indian 
tribe or tribal organization pursuant to a contract, grant, 
cooperative agreement, or compact with the IHS pursuant to the 
Indian Self-Determination Act, or (3) an urban IHP operated by 
a UIO pursuant to a grant or contract with the IHS pursuant to 
Title V of the IHCIA.

Description of provision

    The provision would apply specific sections of the Medicaid 
provisions to the SCHIP program, including: (1) Section 
1932(a)(2)(C) regarding enrollment of Indians in Medicaid 
managed care, and (2) the new Section 1932(h) as added by 
Section 9 of this bill and described above.

For informational purposes only, background on provision contained in 
        amendment of S. 1057

    Section 413, which replaces Section 413 of the Indian 
Health Care Improvement Act Amendments of 2005, as reported (S. 
1057), would add a new Section 413 to the Indian Health Care 
Improvement Act, making a cross-reference to Section 1932(h) of 
the Social Security Act, as amended by the bill, concerning 
treatment of Indians enrolled in Medicaid managed care entities 
and Indian Health Programs and Urban Indian Organizations 
providing services to the Indian enrollees. Section 413 would 
also strike Section 4 of S. 1057, as reported, which included 
amendments to Sections 1911, 1932, 2105, and 2107 of the Social 
Security Act that are covered by previous sections of this 
bill.
    Section 413(a) of S. 1057, as reported, would establish 
payment rules and provider options for Indians enrolled in non-
Indian Medicaid managed care entities with respect to Indian 
Health Programs and Urban Indian Organizations. It would 
require that if an Indian is enrolled in a non-Indian Medicaid 
managed care plan and receives covered health services from an 
Indian Health Program or a UIO, then either (1) the managed 
care entity shall pay the program furnishing the service either 
at an established rate (that is not less than the rate for 
preferred providers) or at another rate negotiated between the 
entity and the Program or Organization, or (2) the State shall 
provide for payment to the Program or Organization at the rate 
that is otherwise applicable (and will make an appropriate 
adjustment of the capitation payment made to the Medicaid 
managed care entity to take into account such payment). It 
would also require the Program or Organization to comply with 
generally applicable Medicaid requirements as a condition of 
payment, would deem any claim submission requirements to be 
satisfied if the Program or Organization submits a claim or 
documentation, and would allow eligible Indian enrollees of a 
non-Indian Medicaid managed care entity to choose a 
participating Program or Organization as their primary care 
provider if the Program or Organization has the capacity.
    Section 413(b) of S. 1057, as reported, would require a 
State (if it elects to offer Medicaid through managed care 
organizations) to offer to make an agreement with an Indian 
Health Program or Urban Indian Organization to serve as the 
managed care organization for eligible Indians the Program or 
Organization serves, if the Program or Organization has 
established a managed care entity that meets applicable quality 
standards.
    Section 413(c) of S. 1057, as reported, would establish 
special rules for Indian Medicaid managed care entities, 
including allowing the Indian entity to restrict enrollment to 
Indians or members of specific tribes, prohibiting a State from 
limiting an Indian's choice of managed care entities to Indian 
entities, and requiring a State to provide default enrollment 
to eligible Indians in an Indian entity and to allow an Indian 
to switch from a non-Indian entity to an Indian entity despite 
State lock-in rules. Section 413(c) would also provide for 
flexibility in Medicaid solvency requirements, advance 
directives, communications with enrollees, and marketing to 
service areas.
    Section 413(d) of S. 1057, as reported, would deem 
requirements that Medicaid managed care programs' health care 
providers have medical malpractice insurance coverage, as a 
condition for contracting with a managed care entity, to be 
satisfied if the Indian Health Program, or an Urban Indian 
Organization that is a federally qualified health center, is 
covered by the Federal Tort Claims Act. Section 413(e) would 
define certain terms for the section.

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

Current law

    No provision.

Description of provision

    The bill would further amend new Section 1139 to add a new 
subsection 1139(f). Beginning January 1, 2007, the Secretary, 
acting through the Administrator of CMS and the Director of the 
IHS, would be required to submit an annual report to Congress. 
The report would cover the enrollment and health status of 
Indians receiving items or services under the health benefit 
programs funded under the Social Security Act during the 
preceding year. The report would include information on: (1) 
total number of Indians enrolled in or receiving items or 
services under each such program, (2) the number of such 
Indians also receiving benefits under programs funded by the 
IHS; (3) general information regarding the health status of 
these Indians, disaggregated with respect to specific diseases 
or conditions, presented consistent with privacy of 
individually identifiable health information; (4) a detailed 
statement on the status of facilities of the Indian Health 
Service, or an Indian Tribe, Tribal Organization, or Urban 
Indian Organization with respect to the facilities' compliance 
with the applicable terms and conditions under Medicare, 
Medicaid and SCHIP (and, in the case of Medicaid and SCHIP, 
under the State plan or waiver authority) and of the progress 
being made by such facilities (under plans submitted under the 
new Sections 1880(b) and 1911(b) added by Section 2 of this 
bill, or otherwise) toward achievement and maintenance of 
compliance; and (5) such other information the Secretary 
determined appropriate.

                       SECTION 11. EFFECTIVE DATE

Current law

    No provision.

Description of provision

    The provision would specify that the effective date of this 
Act would be the same as that for the amendments made by the 
Indian Health Care Improvement Act Amendments of 2006.

                           III. COST ESTIMATE

                                     U.S. Congress,
                               Congressional Budget Office,
                                     Washington, DC, July 10, 2006.
Hon. Charles E. Grassley,
Chairman, Committee on Finance,
U.S. Senate, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 3524, the Medicare, 
Medicaid, and SCHIP Indian Health Care Improvement Act of 2006.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Eric Rollins.
            Sincerely,
                                          Donald B. Marron,
                                                   Acting Director.
    Enclosure.

S. 3524--Medicare, Medicaid, and SCHIP Indian Health Care Improvement 
        Act of 2006

    Summary: S. 3524 would make several changes to Medicaid and 
the State Children's Health Insurance Program (SCHIP) that 
would affect both Indians who are enrolled in those programs 
and the Indian Health Service (IHS). Those changes would 
include exempting Indians from paying cost sharing or premiums 
for certain services and making it easier for IHS and related 
health programs to receive Medicaid payments for services 
provided through managed care arrangements.
    CBO estimates that enacting S. 3524 would increase direct 
spending by $8 million in 2007, by $65 million over the 2007-
2011 period, and by $159 million over the 2007-2016 period. 
Enacting the bill would have no effect on revenues.
    S. 3524 contains no intergovernmental mandates as defined 
in the Unfunded Mandates Reform Act (UMRA). Some provisions of 
the bill, however, would result in additional spending by 
states to comply with new conditions for participating in the 
Medicaid and SCHIP programs. CBO estimates that state spending 
for Medicaid and SCHIP would increase by about $93 million over 
the 2007-2016 period to comply with those new requirements. The 
bill contains no private-sector mandates as defined in UMRA.
    Estimated cost to the Federal Government: The estimated 
budgetary impact of S. 3524 is shown in the following table. 
The costs of this legislation fall within budget function 550 
(health).

----------------------------------------------------------------------------------------------------------------
                                                          By fiscal year, in millions of dollars--
                                           ---------------------------------------------------------------------
                                             2007   2008   2009   2010   2011   2012   2013   2014   2015   2016
----------------------------------------------------------------------------------------------------------------
                                          CHANGES IN DIRECT SPENDING

Exclude Outreach Spending from Limit on
 Administrative Costs:
    Budget Authority......................      0      0      0      0      0      0      0      0      0      0
    Estimated Outlays.....................      *      *      *      *      *      *      *      *      *      *
Exemption from Cost Sharing and Premiums:
    Medicaid
        Estimated Budget Authority........      5     10     10     10     10     10     10     15     15     15
        Estimated Outlays.................      5     10     10     10     10     10     10     15     15     15
    SCHIP
        Budget Authority..................      0      0      0      0      0      0      0      0      0      0
        Estimated Outlays.................      1      1      *     -1      *      *      *      *      *      *
Consultation with Indian Health Programs:
    Estimated Budget Authority............      *      *      1      1      1      1      1      1  .....  .....
    Estimated Outlays.....................      *      *      1      1      1      1      1      1  .....  .....
Medicaid Managed Care Provisions:
    Estimated Budget Authority............      2      3      3      4      4      4      5      5      5      6
    Estimated Outlays.....................      2      3      3      4      4      4      5      5      5      6
Total Changes in Direct Spending:
    Estimated Budget Authority............      7     13     14     15     15     15     16     21     21     22
    Estimated Outlays.....................      8     14     13     14     15     15     16     20     21     22
----------------------------------------------------------------------------------------------------------------
* = Costs or savings of less than $500,000.
NOTES: Components may not sum to totals because of rounding. SCHIP = State Children's Health Insurance Program.

    Basis of estimate: For the purpose of this estimate, CBO 
assumes that S. 3524 will be enacted near the start of fiscal 
year 2007.
    Health programs funded by the Indian Health Service are 
commonly divided into three groups: those operated directly by 
the Indian Health Service, those operated by tribes and tribal 
organizations under self-governance agreements, and those 
operated by urban Indian organizations. For this estimate, they 
are referred to collectively as Indian health programs.

Exclude outreach spending from limit on administrative costs

    Under current law, spending by SCHIP programs on 
administration and certain other activities cannot exceed 10 
percent of overall spending. Section 4 would exclude spending 
on outreach activities to enroll additional Indian children 
from the 10 percent limit.
    CBO estimates that this provision would increase or 
decrease SCHIP spending by less than $500,000 in any fiscal 
year. Federal funding for SCHIP is capped, and we anticipate 
that most states with a significant Indian population would 
spend all of their SCHIP funds under current law. In addition, 
some of the states with unspent funds are not currently 
constrained by the 10 percent limit and thus would not be 
affected by the provision.

Exemption from cost sharing and premiums

    Section 5 would prohibit Medicaid and SCHIP programs from 
charging cost sharing or premiums to Indians for services that 
are provided directly or upon referral by Indian health 
programs. The provision also would prohibit states from 
reducing payments to providers for those services by the amount 
of cost sharing that Indians otherwise would pay.
    Medicaid: CBO anticipates that this provision's budgetary 
effect would stem largely from eliminating cost sharing for 
referral services. Current law already prohibits Indian health 
programs from charging cost sharing to Indians who use their 
services. In addition, Medicaid pays almost all facilities 
operated by IHS and tribes based on an all-inclusive rate that 
is not reduced to account for any cost sharing that Indians 
would otherwise have to pay. Finally, very few states charge 
premiums to their Medicaid enrollees.
    Using Medicaid administrative data, CBO estimates that 
about 270,000 Indians are Medicaid recipients who also use IHS, 
and that federal Medicaid spending on affected services would 
be about $275 per person annually in 2007. The amount of 
affected spending would be relatively low because Medicaid 
already prohibits cost sharing in many instances, such as long-
term care services, emergency services, and services for many 
children and pregnant women. For the affected spending, CBO 
assumes that cost sharing paid by individuals equals 2 percent 
of total spending--Medicaid law limits the extent to which 
states can impose cost sharing--and that eliminating cost 
sharing would increase total spending by about 5 percent as 
individuals consume more services. Overall, CBO estimates that 
the provision would increase federal Medicaid spending by $5 
million in 2007 and by $110 million over the 2007-2016 period.
    State Children's Health Insurance Program: SCHIP 
regulations already prohibit states from charging cost sharing 
or premiums to Indian children enrolled in the program. As a 
result, the provision's impact on SCHIP spending largely 
reflects higher payments to providers and the use of additional 
services by adult enrollees that a handful of states cover in 
waiver programs. CBO estimates that the additional spending 
would total $2 million over the 2007-2016 period. The 
provision's effects would be limited in later years because 
total funding for the program is capped.

Consultation with Indian health programs

    Section 7 would encourage state Medicaid administrators to 
consult regularly the administrators of Indian health programs 
on outstanding Medicaid issues by allowing states to receive 
federal matching funds for the cost of those consultations. 
Those costs would be treated as an administrative expense under 
Medicaid and divided equally between the federal government and 
the states. CBO anticipates that a small number of states would 
take advantage of this provision, increasing federal Medicaid 
spending by less than $500,000 in 2007 and by $7 million over 
the 2007-2016 period.

Medicaid managed care provisions

    Section 9 would make several changes to improve the ability 
of Indian health programs to receive payments for Indians who 
receive Medicaid benefits through managed care arrangements. 
Those changes include:
           Managed care organizations (MCOs) would have 
        to pay Indian health programs at least the rates used 
        for participating providers. States also would have the 
        option of making those payments directly to Indian 
        health programs.
           MCOs would have to accept claims submitted 
        by Indian health programs instead of requiring 
        enrollees to submit claims personally.
           Some requirements that MCOs must now meet to 
        participate in Medicaid would be waived or modified for 
        Indian health programs that seek to operate as MCOs. 
        (For example, MCOs run by Indian health programs would 
        be able to limit enrollment to Indians only.)
           States would be required to offer contracts 
        to Indian health programs seeking to operate their own 
        MCOs.
    Based on administrative data on Medicaid enrollment and 
spending for Indians who receive benefits via managed care, CBO 
estimates that those provisions would increase federal Medicaid 
spending by $2 million in 2007 and $41 million over the 2007-
2016 period. We anticipate that the additional costs would be 
relatively modest because some states already use similar rules 
in their Medicaid managed care programs and Indian health 
programs would have a limited interest in participating as 
MCOs.
    Estimated impact on State, local, and tribal governments: 
S. 3524 contains no intergovernmental mandates as defined in 
the Unfunded Mandates Reform Act. Some provisions of the bill, 
however, would result in additional spending by states to 
comply with new conditions for participating in the Medicaid 
and SCHIP programs. CBO estimates that state spending for 
Medicaid and SCHIP would increase by about $93 million over the 
2007-2016 period to comply with those new requirements.
    Estimated impact on the private sector: The bill contains 
no private-sector mandates as defined in UMRA.
    Previous CBO estimate: On April 26, 2006, CBO transmitted a 
cost estimate for S. 1057, the Indian Health Care Improvement 
Act Amendments of 2005, as reported by the Senate Committee on 
Indian Affairs on March 16, 2006. That bill contains provisions 
that would affect direct spending that are very similar to 
those in S. 3524; we estimated that enacting S. 1057 would 
increase direct spending by $27 million in 2007 and by $398 
million over the 2007-2016 period. The estimated costs for S. 
1057 are higher largely because that bill would exempt all 
Indians enrolled in Medicaid or SCHIP from any cost sharing or 
premiums. By comparison, the exemption in S. 3524 would apply 
to fewer individuals (Medicaid or SCHIP recipients who also use 
IHS) and to a narrower range of services (those provided 
directly or upon referral by Indian health programs).
    Estimate prepared by: Federal costs: Eric Rollins and 
Jeanne De Sa; Impact on State, local, and tribal governments: 
Leo Lex; Impact on the private sector: Jennifer Doleac.
    Estimate approved by: Peter H. Fontaine, Deputy Assistant 
Director for Budget Analysis.

                IV. REGULATORY IMPACT AND OTHER MATTERS


                          A. REGULATORY IMPACT

    Pursuant to paragraph 11(b) of Rule XXVI of the Standing 
Rules of the Senate, the Committee makes the following 
statement concerning the regulatory impact that might be 
incurred in carrying out the provisions of the bill as amended.

Impact on individuals and businesses

    The provisions of the bill are not expected to impose 
additional administrative requirements or regulatory burdens on 
individuals or businesses.

Impact on personal privacy and paperwork

    The provisions of the bill do not reduce personal privacy.

                     B. UNFUNDED MANDATES STATEMENT

    This information is provided in accordance with section 423 
of the Unfunded Mandates Reform Act of 1995 (P.L. 104-4).
    The Committee has determined that the provisions of the 
bill contain no Federal private sector mandates.
    The Committee has determined that the provisions of the 
bill do not impose a Federal intergovernmental mandate on 
State, local, or tribal governments.

                       V. VOTES OF THE COMMITTEE

    In compliance with paragraph 7(b) of rule XXVI of the 
Standing Rules of the Senate, the following statements are made 
concerning the votes taken on the Committee's consideration of 
the bill.

Motion to report the bill

    The bill was ordered favorably reported by voice vote, a 
quorum being present, on June 8, 2006.

Votes on amendments

    No amendments were offered and voted upon.

       VI. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

    Pursuant to the requirements of paragraph 12 of rule XXVI 
of the Standing Rules of the Senate, changes in existing law 
made by the bill, as 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):

SOCIAL SECURITY ACT

           *       *       *       *       *       *       *



     TITLE XI--GENERAL PROVISIONS, PEER REVIEW, AND ADMINISTRATIVE 
SIMPLIFICATION

           *       *       *       *       *       *       *



Part A--General Provision

           *       *       *       *       *       *       *



  EXCLUSION OF CERTAIN INDIVIDUALS AND ENTITIES FROM PARTICIPATION IN 
                MEDICARE AND STATE HEALTH CARE PROGRAMS

    Sec. 1128. (a) Mandatory Exclusion.--The Secretary shall 
exclude the following individuals and entities from 
participation in any Federal health care program (as defined in 
section 1128B(f)):

           *       *       *       *       *       *       *

    (k) Additional Exclusion Waiver Authority for Affected 
Indian Health Programs.--In addition to the authority granted 
the Secretary under subsections (c)(3)(B) and (d)(3)(B) to 
waive an exclusion under subsection (a)(1), (a)(3), (a)(4), or 
(b), the Secretary may, in the case of an Indian Health 
Program, waive such an exclusion upon the request of the 
administrator of an affected Indian Health Program (as defined 
in section 4 of the Indian Health Care Improvement Act) who 
determines that the exclusion would impose a hardship on 
individuals entitled to benefits under or enrolled in a Federal 
health care program.

           *       *       *       *       *       *       *


   CRIMINAL PENALTIES FOR ACTS INVOLVING FEDERAL HEALTH CARE PROGRAMS

    Sec. 1128B. (a) Whoever--
          (1) knowingly and willfully makes or causes to be 
        made any false statement or representation of a 
        material fact in any application for any benefit or 
        payment under a Federal health care program (as defined 
        in subsection (f)),

           *       *       *       *       *       *       *

    (b)(1) Whoever knowingly and willfully solicits or receives 
any remuneration (including any kickback, bribe, or rebate) 
directly or indirectly, overtly or covertly, in cash or in 
kind--

           *       *       *       *       *       *       *

          (4) Subject to such conditions as the Secretary may 
        promulgate from time to time as necessary to prevent 
        fraud and abuse, for purposes of paragraphs (1) and (2) 
        and section 1128A(a), the following transfers shall not 
        be treated as remuneration:
                  (A) Transfers between indian health programs, 
                indian tribes, tribal organizations, and urban 
                indian organizations.--Transfers of anything of 
                value between or among an Indian Health 
                Program, Indian Tribe, Tribal Organization, or 
                Urban Indian Organization, that are made for 
                the purpose of providing necessary health care 
                items and services to any patient served by 
                such Program, Tribe, or Organization and that 
                consist of--
                          (i) services in connection with the 
                        collection, transport, analysis, or 
                        interpretation of diagnostic specimens 
                        or test data;
                          (ii) inventory or supplies;
                          (iii) staff; or
                          (iv) a waiver of all or part of 
                        premiums or cost sharing.
                  (B) Transfers between indian health programs, 
                indian tribes, tribal organizations, or urban 
                indian organizations and patients.--Transfers 
                of anything of value between an Indian Health 
                Program, Indian Tribe, Tribal Organization, or 
                Urban Indian Organization and any patient 
                served or eligible for service from an Indian 
                Health Program, Indian Tribe, Tribal 
                Organization, or Urban Indian Organization, 
                including any patient served or eligible for 
                service pursuant to section 807 of the Indian 
                Health Care Improvement Act, but only if such 
                transfers--
                          (i) consist of expenditures related 
                        to providing transportation for the 
                        patient for the provision of necessary 
                        health care items or services,provided 
that the provision of such transportation is not advertised, nor an 
incentive of which the value is disproportionately large in 
relationship to the value of the health care item or service (with 
respect to the value of the item or service itself or, for preventative 
items or services, the future health care costs reasonably expected to 
be avoided);
                          (ii) consist of expenditures related 
                        to providing housing to the patient 
                        (including a pregnant patient) and 
                        immediate family members or an escort 
                        necessary to assuring the timely 
                        provision of health care items and 
                        services to the patient, provided that 
                        the provision of such housing is not 
                        advertised nor an incentive of which 
                        the value is disproportionately large 
                        in relationship to the value of the 
                        health care item or service (with 
                        respect to the value of the item or 
                        service itself or, for preventative 
                        items or services, the future health 
                        care costs reasonably expected to be 
                        avoided); or
                          (iii) are for the purpose of paying 
                        premiums or cost sharing on behalf of 
                        such a patient, provided that the 
                        making of such payment is not subject 
                        to conditions other than conditions 
                        agreed to under a contract for the 
                        delivery of contract health services.
                  (C) Contract health services.--A transfer of 
                anything of value negotiated as part of a 
                contract entered into between an Indian Health 
                Program, Indian Tribe, Tribal Organization, 
                Urban Indian Organization, or the Indian Health 
                Service and a contract care provider for the 
                delivery of contract health services authorized 
                by the Indian Health Service, provided that--
                          (i) such a transfer is not tied to 
                        volume or value of referrals or other 
                        business generated by the parties; and
                          (ii) any such transfer is limited to 
                        the fair market value of the health 
                        care items or services provided or, in 
                        the case of a transfer of items or 
                        services related to preventative care, 
                        the value of the future health care 
                        costs reasonably expected to be 
                        avoided.
                  (D) Other transfers.--Any other transfer of 
                anything of value involving an Indian Health 
                Program, Indian Tribe, Tribal Organization, or 
                Urban Indian Organization, or a patient served 
                or eligible for service from an Indian Health 
                Program, Indian Tribe, Tribal Organization, or 
                Urban Indian Organization, that the Secretary, 
                in consultation with the Attorney General, 
                determines is appropriate, taking into account 
                the special circumstances of such Indian Health 
                Programs, Indian Tribes, Tribal Organizations, 
                and Urban Indian Organizations, and of patients 
                served by such Programs, Tribes, and 
                Organizations.

           *       *       *       *       *       *       *


                    [NATIONAL COMMISSION ON CHILDREN

    [Sec. 1139. (a)(1) There is hereby established a commission 
to be known as the National Commission on Children (in this 
section referred to as the ``Commission'').
    [(b)(1) The Commission shall consist of--
          [(A) 12 members to be appointed by the President,
          [(B) 12 members to be appointed by the Speaker of the 
        House of Representatives, and
          [(C) 12 members to be appointed by the President pro 
        tempore of the Senate.
    [(2) The President, the Speaker, and the President pro 
tempore shall each appoint as members of the Commission--
          [(A) 4 individuals who--
                  [(i) are representatives of organizations 
                providing services to children,
                  [(ii) are involved in activities on behalf of 
                children, or
                  [(iii) have engaged in academic research with 
                respect to the problems and needs of children,
          [(B) 4 individuals who are elected or appointed 
        public officials (at the Federal, State, or local 
        level) involved in issues and programs relating to 
        children, and
          [(C) 4 individuals who are parents or representatives 
        of parents or parents' organizations.
    [(3) The appointments made pursuant to subparagraphs (B) 
and (C) of paragraph (1) shall be made in consultation with the 
chairmen of committees of the House of Representatives and the 
Senate, respectively, having jurisdiction over relevant Federal 
programs.
    [(c)(1) It shall be the duty and function of the Commission 
to serve as a forum on behalf of the children of the Nation and 
to conduct the studies and issue the report required by 
subsection (d).
    [(2) The Commission (and any committees that it may form) 
shall conduct public hearings in different geographic areas of 
the country, both urban and rural, in order to receive the 
views of a broad spectrum of the public on the status of the 
Nation's children and on ways to safeguard and enhance the 
physical, mental, and emotional well-being of all of the 
children of the Nation, including those with physical or mental 
disabilities, and others whose circumstances deny them a full 
share of the opportunities that parents of the Nation may 
rightfully expect for their children.
    [(3) The Commission shall receive testimony from 
individuals, and from representatives of public and private 
organizations and institutions with an interest in the welfare 
of children, including educators, health care professionals, 
religious leaders, providers of social services, 
representatives of organizations with children as members, 
elected and appointed public officials, and from parents and 
children speaking in their own behalf.
    [(d) The Commission shall submit to the President, and to 
the Committees on Finance and Labor and Human Resources of the 
Senate and the Committees on Ways and Means, Education and 
Labor, and Energy and Commerce of the House of Representatives, 
an interim report no later than March 31, 1990, and a final 
report no later than March 31, 1991, setting forth 
recommendations with respect to the following subjects:
          [(1) Questions relating to the health of children 
        that the Commission shall address include--
                  [(A) how to reduce infant mortality,
                  [(B) how to reduce the number of low-birth-
                weight babies,
                  [(C) how to reduce the number of children 
                with chronic illnesses and disabilities,
                  [(D) how to improve the nutrition of 
                children,
                  [(E) how to promote the physical fitness of 
                children,
                  [(F) how to ensure that pregnant women 
                receive adequate prenatal care,
                  [(G) how to ensure that all children have 
                access to both preventive and acute care health 
                services, and
                  [(H) how to improve the quality and 
                availability of health care for children.
          [(2) Questions relating to social and support 
        services for children and their parents that the 
        Commission shall address include--
                  [(A) how to prevent and treat child neglect 
                and abuse,
                  [(B) how to provide help to parents who seek 
                assistance in meeting the problems of their 
                children,
                  [(C) how to provide counseling services for 
                children,
                  [(D) how to strengthen the family unit,
                  [(E) how children can be assured of adequate 
                care while their parents are working or 
                participating in education or training 
                programs,
                  [(F) how to improve foster care and adoption 
                services,
                  [(G) how to reduce drug and alcohol abuse by 
                children and youths, and
                  [(H) how to reduce the incidence of teenage 
                pregnancy.
          [(3) Questions relating to education that the 
        Commission shall address include--
                  [(A) how to encourage academic excellence for 
                all children at all levels of education,
                  [(B) how to use preschool experiences to 
                enhance educational achievement,
                  [(C) how to improve the qualifications of 
                teachers,
                  [(D) how schools can better prepare the 
                Nation's youth to compete in the labor market,
                  [(E) how parents and schools can work 
                together to help children achieve success at 
                each step of the academic ladder,
                  [(F) how to encourage teenagers to complete 
                high school and remain in school to fulfill 
                their academic potential,
                  [(G) how to address the problems of drug and 
                alcohol abuse by young people,
                  [(H) how schools might lend support to 
                efforts aimed at reducing the incidence of 
                teenage pregnancy, and
                  [(I) how schools might better meet the 
                special needs of children who have physical or 
                mental handicaps.
          [(4) Questions relating to income security that the 
        Commission shall address include--
                  [(A) how to reduce poverty among children,
                  [(B) how to ensure that parents support their 
                children to the fullest extent possible through 
                improved child support collection services, 
                including services on behalf of children whose 
                parents are unmarried, and
                  [(C) how to ensure that cash assistance to 
                needy children is adequate.
          [(5) Questions relating to tax policy that the 
        Commission shall address include--
                  [(A) how to assure the equitable tax 
                treatment of families with children,
                  [(B) the effect of existing tax provisions, 
                including the dependent care tax credit, the 
                earned income tax credit, and the targeted jobs 
                tax credit, on children living in poverty,
                  [(C) whether the dependent care tax credit 
                should be refundable and the effect of such a 
                policy,
                  [(D) whether the earned income tax credit 
                should be adjusted for family size and the 
                effect of such a policy, and
                  [(E) whether there are other tax-related 
                policies which would reduce poverty among 
                children.
          [(6) In addition to addressing the questions 
        specified in paragraphs (1) through (5), the Commission 
        shall--
                  [(A) seek to identify ways in which public 
                and private organizations and institutions can 
                work together at the community level to 
                identify deficiencies in existing services for 
                families and children and to develop 
                recommendations to ensure that the needs of 
                families and children are met, using all 
                available resources, in a coordinated and 
                comprehensive manner, and
                  [(B) assess the existing capacities of 
                agencies to collect and analyze data on the 
                status of children and on relevant programs, 
                identify gaps in the data collection system, 
                and recommend ways to improve the collection of 
                data and the coordination among agencies in the 
                collection and utilization of data.
    [The reports required by this subsection shall be based 
upon the testimony received in the hearings conducted pursuant 
to subsection (c), and upon other data and findings developed 
by the Commission.
    [(e)(1)(A) Members of the Commission shall first be 
appointed not later than 60 days after the date of the 
enactment of this section, for terms ending on March 31, 1991.
    [(B) A vacancy in the Commission shall not affect its 
powers, but shall be filled in the same manner as the vacant 
position was first filled.
    [(2) The Commission shall elect one of its members to serve 
as Chairman of the Commission. The Chairman shall be a non-
voting member of the Commission.
    [(3) A majority of the members of the Commission shall 
constitute a quorum for the transaction of business.
    [(4)(A) The Commission shall meet at the call of the 
Chairman, or at the call of a majority of the members of the 
Commission.
    [(B) The Commission shall meet not less than 4 times during 
the period beginning with the date of the enactment of this 
section and ending with September 30, 1990.
    [(5) Decisions of the Commission shall be according to the 
vote of a simple majority of those present and voting at a 
properly called meeting.
    [(6) Members of the Commission shall serve without 
compensation, but shall be reimbursed for travel, subsistence, 
and other necessary expenses incurred in the performance of 
their duties as members of the Commission.
    [(f)(1) The Commission shall appoint an Executive Director 
of the Commission. In addition to the Executive Director, the 
Commission may appoint and fix the compensation of such 
personnel as it deems advisable. Such appointments and 
compensation may be made without regard to title 5, United 
States Code, that govern appointments in the competitive 
services, and the provisions of chapter 51 and subchapter III 
of chapter 53 of such title that relate to classifications and 
the General Schedule pay rates.
    [(2) The Commission may procure such temporary and 
intermittent services of consultants under section 3109(b) of 
title 5, United States Code, as the Commission determines to be 
necessary to carry out the duties of the Commission.
    [(g) In carrying out its duties, the Commission, or any 
duly organized committee thereof, is authorized to hold such 
hearings, sit and act at such times and places, and take such 
testimony, with respect to matters for which it has a 
responsibility under this section, as the Commission or 
committee may deem advisable.
    [(h)(1) The Commission may secure directly from any 
department or agency of the United States such data and 
information as may be necessary to carry out its 
responsibilities.
    [(2) Upon request of the Commission, any such department or 
agency shall furnish any such data or information.
    [(i) The General Services Administration shall provide to 
the Commission, on a reimbursable basis, such administrative 
support services as the Commission may request.
    [(j) There are authorized to be appropriated through fiscal 
year 1991, such sums as may be necessary to carry out this 
section for each of fiscal years 1989 and 1990.
    [(k)(1) The Commission is authorized to accept donations of 
money, property, or personal services. Funds received from 
donations shall be deposited in the Treasury in a separate fund 
created for this purpose. Funds appropriated for the Commission 
and donated funds may be expended for such purposes as official 
reception and representation expenses, public surveys, public 
service announcements, preparation of special papers, analyses, 
and documentaries, and for such other purposes as determined by 
the Commission to be in furtherance of its mission to review 
national issues affecting children.
    [(2) For purposes of Federal income, estate, and gift 
taxation, money and other property accepted under paragraph (1) 
of this subsection shall be considered as a gift or bequest to 
or for the use of the United States.
    [(3) Expenditure of appropriated and donated funds shall be 
subject to such rules and regulations as may be adopted by the 
Commission and shall not be subject to Federal procurement 
requirements.
    [(1) The Commission is authorized to conduct such public 
surveys as it deems necessary in support of its review of 
national issues affecting children and, in conducting such 
surveys, the Commission shall not be deemed to be an ``agency'' 
for the purpose of section 3502 of title 44, United States 
Code.]

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

    (a) Agreements With States for Medicaid and SCHIP Outreach 
on or Near Reservations To Increase the Enrollment of Indians 
in Those Programs.--
          (1) In general.--In order to improve the access of 
        Indians residing on or near a reservation to obtain 
        benefits under the Medicaid and State children's health 
        insurance programs established under titles XIX and 
        XXI, the Secretary shall encourage the State to take 
        steps to provide for enrollment on or near the 
        reservation. Such steps may include outreach efforts 
        such as the outstationing of eligibility workers, 
        entering into agreements with the Indian Health 
        Service, Indian Tribes, Tribal Organizations, and Urban 
        Indian Organizations to provide out-reach, education 
        regarding eligibility and benefits, enrollment, and 
        translation services when such services are 
        appropriate.
          (2) Construction.--Nothing in subparagraph (A) shall 
        be construed as affecting arrangements entered into 
        between States and the Indian Health Service, Indian 
        Tribes, Tribal Organizations, or Urban Indian 
        Organizations for such Service, Tribes, or 
        Organizations to conduct administrative activities 
        under such titles.
    (b) Requirement To Facilitate Cooperation.--The Secretary, 
acting through the Centers for Medicare & Medicaid Services, 
shall take such steps as are necessary to facilitate 
cooperation with, and agreements between, States and the Indian 
Health Service, Indian Tribes, Tribal Organizations, or Urban 
Indian Organizations with respect to the provision of health 
care items and services to Indians under the programs 
established under title XVIII, XIX, or XXI.
    (c) Nondiscrimination in Qualifications for Payment for 
Services Under Federal Health Care Programs.--
          (1) Requirement to satisfy generally applicable 
        participation requirements.--
                  (A) In general.--A Federal health care 
                program must accept an entity that is operated 
                by the Indian Health Service, an Indian Tribe, 
                Tribal Organization, or Urban Indian 
                Organization as a provider eligible to receive 
                payment under the program for health care 
                services furnished to an Indian on the same 
                basis as any other provider qualified to 
                participate as a provider of health care 
                services under the program if the entity meets 
                generally applicable State or other 
                requirements for participation as a provider of 
                health care services under the program.
                  (B) Satisfaction of state or local licensure 
                or recognition requirements.--Any requirement 
                for participation as a provider of health care 
                services under a Federal health care program 
                that an entity be licensed or recognized under 
                the State or local law where the entity is 
                located to furnish health care services shall 
                be deemed to have been met in the case of an 
                entity operated by the Indian Health Service, 
                an Indian Tribe, Tribal Organization, or Urban 
                Indian Organization if the entity meets all the 
                applicable standards for such licensure or 
                recognition, regardless of whether the entity 
                obtains a license or other documentation under 
                such State or local law. In accordance with 
                section 221 of the Indian Health Care 
                Improvement Act, the absence of the licensure 
                of a health care professional employed by such 
                an entity under the State or local law where 
                the entity is located shall not be taken into 
                account for purposes of determining whether the 
                entity meets such standards, if the 
                professional is licensed in another State.
          (2) Prohibition on federal payments to entities or 
        individuals excluded from participation in federal 
        health care programs or whose state licenses are under 
        the suspension or have been revoked.--
                  (A) Excluded entities.--No entity operated by 
                the Indian Health Service, an Indian Tribe, 
                Tribal Organization, or Urban Indian 
                Organization that has been excluded from 
                participation in any Federal health care 
                program or for which a license is under 
                suspension or has been revoked by the State 
                where the entity is located shall be eligible 
                to receive payment under any such program for 
                health care services furnished to an Indian.
                  (B) Excluded individuals.--No individual who 
                has been excluded from participation in any 
                Federal health care program or whose State 
                license is under suspension or has been revoked 
                shall be eligible to receive payment under any 
                such program for health care services furnished 
                by that individual, directly or through an 
                entity that is otherwise eligible to receive 
                payment for health care services, to an Indian.
                  (C) Federal health care program defined.--In 
                this subsection, the term, ``Federal health 
                care program'' has the meaning given that term 
                in section 1128B(f), except that, for purposes 
                of this subsection, such term shall include the 
                health insurance program under chapter 89 of 
                title 5, United States Code.

           *       *       *       *       *       *       *

    (d) Consultation With Tribal Technical Advisory Group 
(TTAG).--The Secretary shall maintain within the Centers for 
Medicaid & Medicare Services (CMS) a Tribal Technical Advisory 
Group, establishd in accordance with requirements of the 
charter dated September 30, 2003, and in such group shall 
include a representative of the Urban Indian Organizations and 
the Service. The representative of the Urban Indian 
Organization shall be deemed to be an elected officer of a 
tribal government for purposes of applying section 204(b) of 
the Unfunded Mandates Reform Act of 1995 (2 U.S.C. 1534(b)).
    (e) Annual Report on Indians Served by Health Benefit 
Programs Funded Under This Act.--Beginning January 1, 2007, and 
annually thereafter, the Secretary, acting through the 
Administrator of the Centers for Medicare & Medicaid Services 
and the Director of the Indian Health Service, shall submit a 
report to Congress regarding the enrollment and health status 
of Indians receiving items or services under health benefit 
programs funded under this Act during the preceding year. Each 
such report shall include the following:
          (1) The total number of Indians enrolled in, or 
        receiving items or services under, such programs, 
        disaggregated with respect to each such program.
          (2) The number of Indians described in paragraph (1) 
        that alos received health benefits under programs 
        funded by the Indian Health Service.
          (3) General information regarding the health status 
        of the Indians described in paragraph (1), 
        disaggregated with respect to specific diseases or 
        conditions and presented in a manner that is consistent 
        with protections for privacy of individually 
        identifiable health information under sction 264(c) of 
        the Health Insurance Portability and Accountability Act 
        of 1996.
          (4) A detailed statement of the status of facilities 
        of the Indian Health Service or an Indian Tribe, Tribal 
        Organization, or an Urban Indian Organization with 
        respect to such facilities' compliance with the 
        applicable conditions and requirements of titles XVIII, 
        XIX, and XXI, and, in the case of title XIX or XXI, 
        under a State plan under such title or under waiver 
        authority, and of the progress being made by such 
        facilities (under plans submitted under section 
        1880(b), 1911(b) or otherwise) toward the achievement 
        and maintenance of such compliance.
          (5) Such other information as the Secretary 
        determines is appropriate.
    (f) Definition of Indian Tribe; Indian Health Program; 
Tribal Organization; Urban Indian Organization.--In this 
section, the terms ``Indian Tribe'', ``Indian Health Program'', 
``Tribal Organization'', and ``Urban Indian Organization'' have 
the meanings given those terms in section 4 of the Indian 
Health Care Improvement Act.

           *       *       *       *       *       *       *


        TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED


Part E--Miscellaneous Provisions

           *       *       *       *       *       *       *



                   [INDIAN HEALTH SERVICE FACILITIES

    [Sec. 1880.] (a) A hospital or skilled nursing facility of 
the Indian Health Service, whether operated by such Service or 
by an Indian tribe or tribal organization (as those terms are 
defined in section 4 of the Indian health Care Improvement 
Act), shall be eligible for payments under this title, 
notwithstanding sections 18149c) and 1835(d), if and for so 
long as it meets standing sections 1814(c) and 1835(d), if and 
for so long as it meets all of the conditions and requirements 
for such payments which are applicable generally to hospitals 
or skilled nursing facilities (as the case may be) under this 
title.
    [(b) Notwithstanding subsection (a), a hospital or skilled 
nursing facility of the Indian Health Service which does not 
meet all of the conditions and requirements of this title which 
are applicable generally to hospitals or skilled nursing 
facilities (as the case may be), but which submits to the 
Secretary within six months after the date of the enactment of 
this section 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 payments 
under this title), without regard to the extent of its actual 
compliance with such conditions and requirements, during the 
first 12 months after the month in which such plan is 
submitted.
    [(c) Notwithstanding any other provision of this title, 
payments to which any hospital or skilled nursing facility of 
the Indian Health Service is entitled by reason of this section 
shall be placed in a special fund to be held by the Secretary 
and used by him (to such extent or in such amounts as are 
provided in appropriation Acts) exclusively for the purpose of 
making any improvements in the hospitals and skilled nursing 
facilities of such Service which may be necessary to achieve 
compliance with the applicable conditions and requirements of 
this title. The preceding sentence shall cease to apply when 
the Secretary determines and certifies that substantially all 
of the hospitals and skilled nursing facilities of such Service 
in the United States are in compliance with such conditions and 
requirements.
    [(d) The annual report of the Secretary which is required 
by section 701 of the Indian Health Care Improvement Act shall 
include (along with the matters specified in section 403 of 
such Act) a detailed statement of the status of the hospitals 
and skilled nursing facilities of the Service in terms of their 
compliance with the applicable conditions and requirements of 
this title and of the progress being made by such hospitals and 
facilities (under plans submitted under subsection (b) and 
otherwise) toward the achievement of such compliance.]

SEC. 1880. INDIAN HEALTH PROGRAMS.

    (a) Eligibility for Payments.--Subject to subsection (e), 
the Indian Health Service and an Indian Tribe, Tribal 
Organization, or an Urban Indian Organization shall be eligible 
for payments under this title with respect to items and 
services furnished by the Indian Health Service, Indian Tribe, 
Tribal Organization, or Urban Indian Organization if the 
furnishing of such services meets all the conditions and 
requirements which are applicable generally to the furnishing 
of items and services under this title.
    (b) Compliance With Conditions and Requirements.--Subject 
to subsection (e), a facility of the Indian Health Service or 
an Indian Tribe, Tribal Organization, or an Urban Indian 
Organization which is eligible for payment under subsection (a) 
with respect to the furnishing of items and services, but which 
does not meet all of the conditions and requirements of this 
title which are applicable generally to such facility, shall 
make such improvements as are necessary to achieve or maintain 
compliance with such conditions and requirements in accordance 
with a plan submitted to and accepted by the Secretary for 
achieving or maintaining compliance with such conditions and 
requirements, and shall be deemed to meet such conditions and 
requirements (and to be eligible for payment under this title), 
without regard to the extent of its actual compliance with such 
conditions and requirements, during the first 12 months after 
the month in which such plan is submittal.
    (c) Special Fund for Improvement of IHS Facilities.--For 
provisions relating to the authority of the Secretary to place 
payments to which a facility of the Indian Health Service is 
eligible for payment under this title into a special fund 
established under section 401(c)(1) of the Indian Health Care 
Improvement Act, and the requirement to use amounts paid from 
such fund for making improvements in accordance with subsection 
(b), see subparagraphs (A) and (B) of section 401(c)(1) of such 
Act.
    (d) Direct Billing.--For provisions relating to the 
authority of a Tribal Health Program or an Urban Indian 
Organization to elect to directly bill for, and receive payment 
for, health care items and services provided by such Program or 
Organization for which payment is made under this title, see 
section 401(d) of the Indian Health Care Improvement Act.
    (e)(1)(A) Notwithstanding section 1835(d), subject to 
subparagraph (B), the Secretary shall make payment under part B 
to a hospital or an ambulatory care clinic (whether provider-
based or freestanding) that is operated by te Indian Health 
Service or by an Indian tribe or tribal organization (as 
defined for purposes of subsection (a)) for services described 
in paragraph (2) (and for items and services furnished during 
the 5-year period beginning on January 1, 2005, all items and 
services for which payment may be made under part B) furnished 
in or at the direction of the hospital or clinic under the same 
situations, terms, and conditions as would apply if the 
services were furnished in or at the direction of such a 
hospital or clinic that was not operated by such Service, 
tribe, or organization.

           *       *       *       *       *       *       *

    (3) Subsection (c) and section 401(c)(1) of the Indian 
Health Improvement Act shall not apply to payments made under 
this subsection.
    [(f) 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 organziations and for which payment 
may be made under this title, see section 405 of the Indian 
Health Care Improvement Act (25 U.S.C. 1645).]
    (f) Definitions.--In this section, the terms ``Indian 
Health Program,'' ``Indian Tribe'', ``Service Unit'', ``Tribal 
Health Program'', ``Tribal Organization'', and ``Urban Indian 
Organization'', have the meanings given those terms in section 
4 of the Indian Health Care Improvement Act.

TITLE XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

           *       *       *       *       *       *       *


                   STATE PLANS FOR MEDICAL ASSISTANCE

    Sec. 1902. (a) A State plan for medical assistance must--

           *       *       *       *       *       *       *

          (69) provide that the State must comply with any 
        requirements determined by the Secretary to be 
        necessary for carrying out the Medicaid Integrity 
        Program established under section 1936; [and]
          (70) at the option of the State and notwithstanding 
        paragraphs (1), (10)(B), and (23), provide for the 
        establishment of a non-emergency medical transportation 
        brokerage program in order to more cost-effectively 
        provide transportation for individuals eligible for 
        medical assistance under the State plan who need access 
        to medical care or services and have no other means of 
        transportation which--

           *       *       *       *       *       *       *

                  (B) may be conducted under contract with a 
                broker who--
                          (i) is selected through a competitive 
                        bidding process based on the State's 
                        evaluation of the broker's experience, 
                        performance, references, resources, 
                        qualifications, and costs;

           *       *       *       *       *       *       *

                          (iv) complies with such requirements 
                        related to prohibitions on referrals 
                        and conflict of interest as the 
                        Secretary shall establish (based on the 
                        prohibitions on physician referrals 
                        under section 1877 and such other 
                        prohibitions and requirements as the 
                        Secretary determines to be 
                        appropriate)[.] ; and
          (71) in the case of any State in which the Indian 
        Health Service operates or funds health care programs, 
        or in which 1 or more Indian Health Programs or Urban 
        Indian Organizations (as such terms are defined in 
        section 4 of the Indian Health Care Improvement Act) 
        provide health care in the State for which medical 
        assistance is available under such title, provide for a 
        process under which the State seeks advice on a 
        regular, ongoing basis from designees of such Indian 
        Health Programs and Urban Indian Organizations on 
        matters relating to the application of this title that 
        are likely to have a direct effect on such Indian 
        Health Programs and Urban Indian Organizations and 
        that--
                  (A) shall include solicitation of advice 
                prior to submission of any plan amendments, 
                waiver requests, and proposals for 
                demonstration projects likely to have a direct 
                effect on Indians, Indian Health Programs, or 
                Urban Indian Organizations; and
                  (B) may include appointment of an advisory 
                committee and of a designee of such Indian 
                Health Programs and Urban Indian Organizations 
                to the medical care advisory committee advising 
                the State on its State plan under this title.
    (e)(1)(A) * * *
          (12) At the option of the State, the plan may provide 
        that an individual who is under an age specified by the 
        State (not to exceed 19 years of age) and who is 
        determined to be eligible for benefits under a State 
        plan approved under this title under subsection 
        (a)(10)(A) shall remain eligible for those benefits 
        until the earlier of--
                  (A) the end of a period (not to exceed 12 
                months) following the determination; or
                  (B) the time that the individual exceeds that 
                age.
          (13) Notwithstanding any other requirement of this 
        title or any other provision of Federal or State law, a 
        State shall disregard the following property for 
        purposes of determining eligibility for medical 
        assistance under this title:
                  (A) Property, including real property and 
                improvements, located on a reservation, 
                including any federally recognized Indian 
                Tribe's reservation, pueblo, or colony, 
                including former reservations in Oklahoma, 
                Alaska Native regions established by the Alaska 
                Native Claims Settlement Act, and Indian 
                allotments on or near a reservation as 
                designated and approved by the Bureau of Indian 
                Affairs of the Department of the Interior.
                  (B) For any federally recognized Tribe not 
                described in subparagraph (A), property located 
                within the most recent boundaries of a prior 
                Federal reservation.
                  (C) Ownership interests in rents, leases, 
                royalties, or usage rights related to natural 
                resources (including extraction of natural 
                resources or harvesting of timber, other plants 
                and plant products, animals, fish, and 
                shellfish) resulting from the exercise of 
                federally protected rights.
                  (D) Ownership interests in or usage rights to 
                items not covered by subparagraphs (A) through 
                (C) that have unique religious, spiritual, 
                traditional, or cultural significance or rights 
                that support subsistence or a traditional 
                lifestyle according to applicable tribal law or 
                custom.

TITLE XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

           *       *       *       *       *       *       *



                           PAYMENT TO STATES

    Sec. 1903. (a) From the sums appropriated therefor, the 
Secretary (except as otherwise provided in this section) shall 
pay to each State which has a plan approved under this title, 
for each quarter, beginning with the quarter commencing January 
1, 1996--

           *       *       *       *       *       *       *

    (x)(1) For purposes of subsection (i)(23), the requirement 
of this subsection is, with respect to an individual declaring 
to be a citizen or national of the United States, that, subject 
to paragraph (2), there is presented satisfactory documentary 
evidence of citizenship or nationality (as defined in paragraph 
(3)) of the individual.

           *       *       *       *       *       *       *

          (3)(A) For purposes of this subsection, the term 
        ``satisfactory documentary evidence of citizenship or 
        nationality'' means--
                  (i) any document described in subparagraph 
                (B); or
                  (ii) a document described in subparagraph (C) 
                and a document described in subparagraph (D).
          (B) The following are documents described in this 
        subparagraph.
                  (i) A United States passport.

           *       *       *       *       *       *       *

                          (v)(I) Except as provided in 
                        subclause (II), a document issued by a 
                        federally-recognized Indian tribe 
                        evidencing membership or enrollment in, 
                        or affiliation with, such tribe.
                          (II) With respect to those federally-
                        recognized Indian tribes located within 
                        States having an international border 
                        whose membership includes individuals 
                        who are not citizens of the United 
                        States, the Secretary shall, after 
                        consulting with such tribes, issue 
                        regulations authorizing the 
                        presentation of such other forms of 
                        documentation (including tribal 
                        documentation, if appropriate) that the 
                        Secretary determines to be satisfactory 
                        documentary evidence of citizenship or 
                        nationality for purposes of satisfying 
                        the requirement of this subsection.
                          [(v)](vi) Such other document as the 
                        Secretary may specify, by regulation, 
                        that provides proof of United States 
                        citizenship or nationality and that 
                        provides a reliable means of 
                        documentation of personal identity.

           *       *       *       *       *       *       *

    (b) Table of Contents.--The table of contents for this Act 
is as follows:

           *       *       *       *       *       *       *


                   [INDIAN HEALTH SERVICE FACILITIES

    [Sec. 1911. (a) 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), whether operated by such Service or by 
an Indian tribe or tribal organization (as those terms are 
defined in section 4 of the Indian Health Care Improvement 
Act), shall be eligible for reimbursement for medical 
assistance provided under a State plan if and for so long as it 
meets all of the conditions and requirements which are 
applicable generally to such facilities under this title.
    [(b) Notwithstanding subsection (a), 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 
of the conditions and requirements of this title which are 
applicable generally to such facility, but which submits to the 
Secretary within six months after the date of the enactment of 
this section 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 title), without regard to the extent 
of its actual compliance with such conditions and requirements, 
during the first twelve months after the month in which such 
plan is submitted.
    [(c) The Secretary is authorized to enter into agreements 
with the State agency for the purpose of reimbursing such 
agency for health care and services provided in Indian Health 
Service facilities to Indians who are eligible for medical 
assistance under the State plan.
    [(d) 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 provides by a hospital or 
clinic of such tribes or organizations and for which payment 
may be made under this title, see section 405 of the Indian 
Health Care Improvement Act (25 U.S.C. 1645).]

SEC. 1911. INDIAN HEALTH PROGRAMS.

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

           *       *       *       *       *       *       *


USE OF ENROLLMENT FEES, PREMIUMS, DEDUCTIONS, COST SHARING, AND SIMILAR 
                                CHARGES

    Sec. 1916. (a) Subject to subsections (g) [and (i)], (i), 
and (j), the State plan shall provide that in the case of 
individuals described in subparagraph (A) or (E)(i) of section 
1902(a)(10) who are eligible under the plan--

           *       *       *       *       *       *       *

    (j) No Premiums or Cost Sharing for Indians Furnished Items 
or Services Directly by Indian Health Programs or Through 
Referral Under the Contract Health Service.--
          (1) No cost sharing for items or services furnished 
        to indians through indian health programs.--
                  (A) In general.--No enrollment fee, premium, 
                or similar charge, and no deduction, copayment, 
                cost sharing, or similar charge shall be 
                imposed against an Indian who is furnished an 
                item or service directly by the Indian Health 
                Service, an Indian Tribe, Tribal Organization, 
                or Urban Indian Organization or through 
                referral under the contract health service for 
                which payment may be made under this title.
                  (B) No reduction in amount of payment to 
                indian health providers.--Payment due under 
                this title to the Indian Health Service, an 
                Indian Tribe, Tribal Organization, or Urban 
                Indian Organization, or a health care provider 
                through referral under the contract health 
                service for the furnishing of an item or 
                service to an Indian who is eligible for 
                assistance under such title, may not be reduced 
                by the amount of any enrollment fee, premium, 
                or similar charge, or any deduction, copayment, 
                cost sharing, or similar charge that would be 
                due from the Indian but for the operation of 
                subparagraph (A).
          (2) Rule of construction.--Nothing in this subsection 
        shall be construed as restricting the application of 
        any other limitations on the imposition of premiums or 
        cost sharing that may apply to an individual receiving 
        medical assistance under this title who is an Indian.
          (3) Definitions.--In this subsection the terms 
        ``contract health services'', ``Indian,'', ``Indian 
        Tribe'', ``Tribal Organization'', and ``Urban Indian 
        Organization'' have the meanings given those terms in 
        section 4 of the Indian Health Care Improvement Act.

         STATE OPTION FOR ALTERNATIVE PREMIUMS AND COST SHARING

    Sec. 1916A. (a) State Flexibility.--
          (1) In general.--Notwithstanding sections 1916 and 
        1902(a)(10)(B), a State, at its option and through a 
        State plan amendment, may impose premiums and cost 
        sharing for any group of individuals (as specified by 
        the State) and for any type of services (other than 
        drugs for which cost sharing may be imposed under 
        subsection (c)), and may vary such premiums and cost 
        sharing among such groups or types, consistent with the 
        limitations established under this section. Nothing in 
        this section shall be construed as superseding (or 
        preventing the application of) [section 
        1916(g)]subsections (g), (i), or (j) of section 1916.

           *       *       *       *       *       *       *


       LIENS, ADJUSTMENTS AND RECOVERIES, AND TRANSFERS OF ASSETS

    Sec. 1917. (a)(1) No lien may be imposed against the 
property of any individual prior to his death on account of 
medical assistance paid or to be paid on his behalf under the 
State plan, except--

           *       *       *       *       *       *       *

    (b)(1) No adjustment or recovery of any medical assistance 
correctly paid on behalf of an individual under the State plan 
may be made, except that the State shall seek adjustment or 
recovery of any medical assistance correctly paid on behalf of 
an individual under the State plan in the case of the following 
individuals:

           *       *       *       *       *       *       *

          (3) (A) The State agency shall establish procedures 
        (in accordance with standards specified by the 
        Secretary) under which the agency shall waive the 
        application of this subsection (other than paragraph 
        (1)(C)) if such application would work an undue 
        hardship as determined on the basis of criteria 
        established by the Secretary.
          (B) The standards specified by the Secretary under 
        subparagraph (A) shall require that the procedures 
        established by the State agency under subparagraph (A) 
        exempt income, resources, and property that are exempt 
        from the application of this subsection as of April 1, 
        2003, under manual instructions issued to carry out 
        this subsection (as in effect on such date) because of 
        the Federal responsibility for Indian Tribes and Alaska 
        Native Villages. Nothing in this subparagraph shall be 
        construed as preventing the Secretary from providing 
        additional estate recovery exemptions under this title 
        for Indians.

           *       *       *       *       *       *       *


                  PROVISIONS RELATING TO MANAGED CARE

    Sec. 1932. (a) State Option To Use Managed Care.--

           *       *       *       *       *       *       *

    (g) Identification of Patients for Purposes of Making DSH 
Payments.--Each contract with a managed care entity under 
section 1903(m) or under section 1905(t)(3) shall require the 
entity either--
          (1) to report to the State information necessary to 
        determine the hospital services provided under the 
        contract (and the identity of hospitals providing such 
        services) for purposes of applying sections 
        1886(d)(5)(F) and 1923; or
          (2) to include a sponsorship code in the 
        identification card issued to individuals covered under 
        this title in order that a hospital may identify a 
        patient as being entitled to benefits under this title.
    (h) Special Rules With Respect to Indian Enrollees, Indian 
Health Care Providers, and Indian Managed Care Entities.--
          (1) Enrollee option to select an indian health care 
        provider as primary care provider.--In the case of a 
        non-Indian Medicaid managed care entity that--
                  (A) has an Indian enrolled with the entity; 
                and
                  (B) has an Indian health care provider that 
                is participating as a primary care provider 
                within the network of the entity,
insofar as the Indian is otherwise eligible to receive services 
from such Indian health care provider and the Indian health 
care provider has the capacity to provide primary care services 
to such Indian, the contract with the entity under section 
1903(m) or under section 1905(t)(3) shall require, as a 
condition of receiving payment under such contract, that the 
Indian shall be allowed to choose such Indian health care 
provider as the Indian's primary care provider under the 
entity.
          (2) Assurance of payment to indian health care 
        providers for provision of covered services.--Each 
        contract with a managed care entity under section 
        1903(m) or under section 1905(t)(3) shall require any 
        such entity that has a significant percentage of Indian 
        enrollees (as determined by the Secretary), as a 
        condition of receiving payment under such contract to 
        satisfy the following requirements.
                  (A) Demonstration of participating indian 
                health care providers or application of 
                alternative payment arrangements.--Subject to 
                subparagraph (E), to--
                          (i) demonstrate that the number of 
                        Indian health care providers that are 
                        participating providers with respect to 
                        such entity are sufficient to ensure 
                        timely access to covered Medicaid 
                        managed care services for those 
                        enrollees who are eligible to receive 
                        services from such providers; or
                          (ii) agree to pay Indian health care 
                        providers who are not participating 
                        providers with the entity for covered 
                        Medicaid managed care services provided 
                        to those enrollees who are eligible to 
                        receive services from such providers at 
                        a rate equal to the rate negotiated 
                        between such entity and the provider 
                        involved or, if such a rate has not 
                        been negotiated, at a rate that is not 
                        less than the level and amount of 
                        payment which the entity would make for 
                        the services if the services were 
                        furnished by a participating provider 
                        which is not an Indian health care 
                        provider.
                  (B) Prompt payment.--To agree to make prompt 
                payment (in accordance with rules applicable to 
                managed care entities) to Indian health care 
                providers that are participating providers with 
                respect to such entity or, in the case of an 
                entity to which subparagraph (A)(ii) or (E) 
                applies, that the entity is required to pay in 
                accordance with that subparagraph.
                  (C) Satisfaction of claim requirement.--To 
                deem any requirement for the submission of a 
                claim or other documentation for services 
                covered under subparagraph (A) by the enrollee 
                to be satisfied through the submission of a 
                claim or other documentation by an Indian 
                health care provider that is consistent with 
                section 403(h) of the Indian Health Care 
                Improvement Act.
                  (D) Compliance with generally applicable 
                requirements.--
                          (i) In general.--Subject to clause 
                        (ii), as a condition of payment under 
                        subparagraph (A), an Indian health care 
                        provider shall comply with the 
                        generally applicable requirements of 
                        this title, the State plan, and such 
                        entity with respect to covered Medicaid 
                        managed care services provided by the 
                        Indian health care provider tothe same 
extent that non-Indian providers participating with the entity must 
comply with such requirements.
                          (ii) Limitations on compliance with 
                        managed care entity generally 
                        applicable requirements.--An Indian 
                        health care provider--
                                  (I) shall not be required to 
                                comply with a generally 
                                applicable requirement of a 
                                managed care entity described 
                                in clause (i) as a condition of 
                                payment under subparagraph (A) 
                                if such compliance would 
                                conflict with any other 
                                statutory or regulatory 
                                requirements applicable to the 
                                Indian health care provider; 
                                and
                                  (II) shall only need to 
                                comply with those generally 
                                applicable requirements of a 
                                managed care entity described 
                                in clause (i) as a condition of 
                                payment under subparagraph (A) 
                                that are necessary for the 
                                entity's compliance with the 
                                State plan, such as those 
                                related to care management, 
                                quality assurance, and 
                                utilization management.
                  (E) Application of special payment 
                requirements for federally-qualified health 
                centers and encounter rate for services 
                provided by certain indian health care 
                providers.--
                          (i) Federally-qualified health 
                        centers.--
                                  (I) Managed care entity 
                                payment requirement.--To agree 
                                to pay any Indian health care 
                                provider that is a federally-
                                qualified health center but not 
                                a participating provider with 
                                respect to the entity, for the 
                                provision of covered Medicaid 
                                managed care services by such 
                                provider to an Indian enrollee 
                                of the entity at a rate equal 
                                to the amount of payment that 
                                the entity would pay a 
                                federally-qualified health 
                                center that is a participating 
                                provider with respect to the 
                                entity but is not an Indian 
                                health care provider for such 
                                services.
                                  (II) Continued application of 
                                state requirement to make 
                                supplemental payment.--Nothing 
                                in subclause (I) or 
                                subparagraph (A) or (B) shall 
                                be construed as waiving the 
                                application of section 
                                1902(bb)(5) regarding the State 
                                plan requirement to make any 
                                supplemental payment due under 
                                such section to a federally-
                                qualified health center for 
                                services furnished by such 
                                center to an enrollee of a 
                                managed care entity (regardless 
                                of whether the federally-
                                qualified health center is or 
                                is not a participating provider 
                                with the entity).
                                  (ii) Continued application of 
                                encounter rate for services 
                                provided by certain indian 
                                health care providers.--If the 
                                amount paid by a managed care 
                                entity to an Indian health care 
                                provider that is not a 
                                federally-qualified health 
                                center and that has elected to 
                                receive payment under this 
                                title as an Indian Health 
                                Service provider under the July 
                                11, 1996, Memorandum of 
                                Agreement between the Health 
                                Care Financing Administration 
                                (now the Centers for Medicare & 
                                Medicaid Services) and the 
                                Indian Health Service for 
                                services provided by such 
                                provider to an Indian enrollee 
                                with the managed care entity is 
                                less than the encounter rate 
                                that applies to the provision 
                                of such services under such 
                                memorandum, the State plan 
                                shall provide for payment to 
                                the Indian health care provider 
                                of the difference between the 
                                applicable encounter rate under 
                                such memorandum and the amount 
                                paid by the managed care entity 
                                to the provider for such 
                                services.
                  (F) Construction.--Nothing in this paragraph 
                shall be construed as waiving the application 
                of section 1902(a)(30)(A) (relating to 
                application of standards to assure that 
                payments are consistent with efficiency, 
                economy, and quality of care).
          (3) Offering of managed care through indian medicaid 
        managed care entities.--If--
                  (A) a State elects to provide services 
                through Medicaid managed care entities under 
                its Medicaid managed care program; and
                  (B) an Indian health care provider that is 
                funded in whole or in part by the Indian Health 
                Service, or a consortium composed of 1 or more 
                Tribes, Tribal Organizations, or Urban Indian 
                Organizations, and which also may include the 
                Indian Health service, has established an 
                Indian Medicaid managed care entity in the 
                State that meets generally applicable standards 
                required of such an entity under such Medicaid 
                managed care program,
the State shall offer to enter into an agreement with the 
entity to serve as a Medicaid managed care entity with respect 
to eligible Indians served by such entity under such program.
          (4) Special rules for indian managed care entities.--
        The following are special rules regarding the 
        application of a Medicaid managed care program to 
        Indian medicaid managed care entities:
                  (A) Enrollment.--
                          (i) Limitation to indians.--An Indian 
                        medicaid managed care entity may 
                        restrict enrollment under such program 
                        to Indians and to members of specific 
                        Tribes in the same manner as Indian 
                        Health Programs may restrict the 
                        delivery of services to such Indians 
                        and tribal members.
                          (ii) No less choice of plans.--Under 
                        such program the state may not limit 
                        the choice of an Indian among Medicaid 
                        managed care entities only to Indian 
                        Medicaid managed care entities or to be 
                        more restrictive than the choice of 
                        managed care entities offered to 
                        individuals who are not Indians.
                          (iii) Default enrollment.--
                                  (I) In general.--If such 
                                program of a state requires the 
                                enrollment of Indians in a 
                                medicaid managed care entity in 
                                order to receive benefits, the 
                                state, taking into 
                                consideration the criteria 
                                specified in sub-section 
                                (a)(4)(D)(ii)(I), shall provide 
                                for the enrollment of Indians 
                                described in subclause (II) who 
                                are not otherwise enrolled with 
                                such an entity in an Indian 
                                Medicaid managed care entity 
                                described in such clause.
                                  (II) Indian described.--An 
                                Indian described in this 
                                subclause, with respect to an 
                                Indian Medicaid managed care 
                                entity, is an Indian who, based 
                                upon the service area and 
                                capacity of the entity, is 
                                eligible to be enrolled with 
                                the entity consistent with 
                                subparagraph (A).
                          (iv) Exception to state lockin.--A 
                        request by an Indian who is enrolled 
                        under such program with a non-Indian 
                        Medicaid managed care entity to change 
                        enrollment with that entity to 
                        enrollment with an Indian Medicaid 
                        managed care entity shall be considered 
                        cause for granting such request under 
                        procedures specified by the Secretary.
                  (B) Flexibility in application of solvency.--
                In applying section 1903(m)(1) to an Indian 
                medicaid managed care entity--
                          (i) any reference to a ``State'' in 
                        subparagraph (A)(ii) of that section 
                        shall be deemed to be a reference to 
                        the ``Secretary''; and
                          (ii) the entity shall be deemed to be 
                        a public entity described in 
                        subparagraph (C)(ii) of that section.
                  (C) Exceptions to advance directives.--The 
                Secretary may modify or waive the requirements 
                of section 1902(w) (relating to provision of 
                written materials on advance directives) 
                insofar as the Secretary finds that the 
                requirements otherwise imposed are not an 
                appropriate or effective way of communicating 
                the information to Indians.
                  (D) Flexibility in information and 
                marketing.--
                          (i) Materials.--The Secretary may 
                        modify requirements under subsection 
                        (a)(5) to ensure that information 
                        described in that subsection is 
                        provided to enrollees and potential 
                        enrollees of Indian medicaid managed 
                        care entities in a culturally 
                        appropriate and understandable manner 
                        that clearly communicates to such 
                        enrollees and potential enrollees their 
                        rights, protections, and benefits.
                          (ii) Distribution of marketing 
                        materials.--The provisions of 
                        subsection (d)(2)(B) requiring the 
                        distribution of marketing materials to 
                        an entire service area shall be deemed 
                        satisfied in the case of an Indian 
                        medicaid managed care entity that 
                        distributes appropriate materials only 
                        to those Indians who are potentially 
                        eligible to enroll with the entity in 
                        the service area.
          (5) Malpractice insurance.--Insofar as, under a 
        Medicaid managed care program, a health care provider 
        is required to have medical malpractice insurance 
        coverage as a condition of contracting as a provider 
        with a Medicaid managed care entity, an Indian health 
        care provider that is--
                  (A) a federally-qualified health center that 
                is covered under the Federal Tort Claims Act 
                (28 U.S.C. 1346(b), 2671 et seq.);
                  (B) providing health care services pursuant 
                to a contract or compact under the Indian Self-
                Determinatin and education Assistance Act (25 
                U.S.C. 450 et seq.) that are covered under the 
                Federal Tort Claims Act (28 U.S.C. 1346(b), 
                2671 et seq.); or
                  (C) the Indian Health Service providing 
                health care services that are covered under the 
                Federal Tort Claims Act (28 U.S.C. 1346(b), 
                2671 et seq.
are deemed to satisfy such requirement.
          (6) Definitions.--For purposes of this subsection:
                  (A) Indian health care provider.--The term 
                ``Indian health care provider'' means an Indian 
                Health Program or an Urban Indian Organization.
                  (B) Indian; indian health program; service; 
                tribe, tribal organization; urban indian 
                organization.--The terms ``Indian'', ``Indian 
                Health Program'', ``Service'', ``Tribe'', 
                ``tribal organization'', ``Urban Indian 
                Organization'' have the meanings given such 
                terms in section 4 of the Indian Health Care 
                Improvement act.
                  (C) Indian medicaid managed care entity.--The 
                term ``Indian Medicaid managed care entity'' 
                means a managed care entity that is controlled 
                (within the meaning of the last sentence of 
                section 1903(m)(1)(C)) by the Indian Health 
                Service, a Tribe, Tribal Organization, or Urban 
                Indian Organization, or a consortium, which may 
                be composed of 1 or more Tribes, Tribal 
                Organizations, or Urban Indian Organizations, 
                and which also may include the Service.
                  (D) Non-indian medicaid managed care 
                entity.--The term ``non-Indian Medicaid managed 
                care entity'' means a managed care entity that 
                is not an Indian Medicaid managed care entity.
                  (E) Covered medicaid managed care services.--
                The term ``covered Medicaid managed care 
                services'' means, with respect to an individual 
                enrolled with a managed care entity, items and 
                services that are within the scope of items and 
                services for which benefits are available with 
                respect to the individual under the contract 
                between the entity and the State involved.
                  (F) Medicaid managed care program.--The term 
                ``Medicaid managed care program'' means a 
                program under sections 1903(m) and 1932 and 
                includes a managed care program operating under 
                a waiver under section 1915(b) or 1115 or 
                otherwise.

           *       *       *       *       *       *       *


TITLE XXI--STATE CHILDREN'S HEALTH INSURANCE PROGRAM

           *       *       *       *       *       *       *


   GENERAL CONTENTS OF STATE CHILD HEALTH PLAN; ELIGIBILITY; OUTREACH

    Sec. 2102 (a) General Background and Description.--A State 
child health plan shall include a description, consistent with 
the requirements of this title, of--

           *       *       *       *       *       *       *

    (b) General Description of Eligibility Standards and 
Methodology.--
          (1) Eligibility standards.--

           *       *       *       *       *       *       *

          (3) Eligibility screening; coordination with other 
        health coverage programs.--The plan shall include a 
        description of procedures to be used to ensure--
                  (A) through both intake and followup 
                screening, that only targeted low-income 
                children are furnished child health assistance 
                under the State child health plan;

           *       *       *       *       *       *       *

                  (D) the provision of child health assistance 
                to targeted low-income children in the State 
                who are Indians, [(as defined in section 4(c) 
                of the Indian Health Care Improvement Act, 25 
                U.S.C. 1603(c))], including how the State will 
                ensure that payments are made to Indian Health 
                Program and Urban Indian Organization operating 
                in the State for the provision of such 
                assistance; and

           *       *       *       *       *       *       *


                           PAYMENTS TO STATES

    Sec. (a) Payments.--

           *       *       *       *       *       *       *

    (c) Limitation on Certain Payments for certain 
Expenditures.--
          (1) General limitations.--Funds provided to a State 
        under this title shall only be used to carry out the 
        purposes of this title (as described in section 2101), 
        and any health insurance coverage provided with such 
        funds may include coverage of abortion only if 
        necessary to save the life of the mother or if the 
        pregnancy is the result of an act of rape or incest.
          (2) Limitation on expenditures not used for medicaid 
        or health insurance assistance.--
                  (A) In general.--Except as provided in this 
                paragraph, the amount of payment that may be 
                made under subsection (a) for a fiscal year for 
                expenditures for items described in paragraph 
                (1)(D) of such subsection shall not exceed 10 
                percent of the total amount of expenditures for 
                which payment is made under subparagraphs (A), 
                (C), and (D) of paragraph (1) of such 
                subsection.

           *       *       *       *       *       *       *

                  (C) Nonapplication to expenditures for 
                outreach to increase the enrollment of indian 
                children under this title and title xix.--The 
                limitation under subparagraph (A) on 
                expenditures for items described in subsection 
                (a)(1)(D) shall not apply in the case of 
                expenditures for outreach activities to 
                families of Indian children likely to be 
                eligible for child health assistance under the 
                plan or medical assistance under the State plan 
                under title XIX (or under a waive of such 
                plan), to inform such families of the 
                availability of, and to assist them in 
                enrolling their children in, such plans, 
                including such activities conducted under 
                grants, contracts, or agreements entered into 
                under section 1139(a).
          (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] program, other than a health care 
                program operated or financed by the Indian 
                Health Service or by an Indian Tribe, Tribal 
                Organization, or Urban Indian Organization, as 
                identified by the Secretary. For purposes of 
                this paragraph, rules similar to the rules for 
                overpayments under section 1903(d)(2) shall 
                apply.

           *       *       *       *       *       *       *


    STRATEGIC OBJECTIVES AND PERFORMANCE GOALS; PLAN ADMINISTRATION

    Sec. 2107. (a) Strategic Objectives and Performance 
Goals.--

           *       *       *       *       *       *       *

    (e) Application of Certain General Provisions.--The 
following sections of this Act shall apply to States under this 
title in the same manner as they apply to a State under title 
XIX:
          (1) Title xix provisions.--
                  (A) Section 1902(a)(4)(C) (relating to 
                conflict of interest standards).

           *       *       *       *       *       *       *

                  (B) Section 1902(a)(71) (relating to the 
                option of certain States to seek advice from 
                designees of Indian Health Programs and Urban 
                Indian Organizations).
                  (C) Section 1902(c)(13) (relating to 
                disregard of certain property for purposes of 
                making eligibility determinations).
                  [(B)](D) Paragraphs (2), (16), and (17) of 
                section 1903(i) (relating to limitations on 
                payment).
                  [(C)](E) Section 1903(w) (relating to 
                limitations on provider taxes and donations).
                  (F) Section 1911 (relating to Indian Health 
                Programs, other than subsection (d) of such 
                section).
                  [(D)](G) Section 1920A (relating to 
                presumptive eligibility for children).

           *       *       *       *       *       *       *

                  (H) Subsections (a)(2)(C) and (h) of section 
                1932.

           *       *       *       *       *       *       *


                              DEFINITIONS

    Sec. 2110. (a) Child Health Assistance.--For purposes of 
this title, the term ``child health assistance'' means payment 
for part or all of the cost of health benefits coverage for 
targeted low-income children that includes any of the following 
(and includes, in the case described in section 
2105(a)(1)(D)(i), payment for the part or all of the cost of 
providing any of the following), as specified under the State 
plan:

           *       *       *       *       *       *       *

    (c) Additional Definitions.--For purposes of this title:
          (1) Child.--The term child means an individual under 
        19 years of age.

           *       *       *       *       *       *       *

          (9) Indian; indian health program; indian tribe; 
        etc.--The terms ``Indian'', ``Indian Health Program'', 
        ``Indian Tribe'', ``Tribal Organization'', and ``Urban 
        Indian Organization'' have the meanings given those 
        terms in section 4 of the Indian Health Care 
        Improvement Act.

           *       *       *       *       *       *       *




                                
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