    [Senate Report 110-197]
    [From the U.S. Government Publishing Office]

                                                           Calendar No. 421
    110th Congress                                                   Report
                                     SENATE
     1st Session                                                    110-197

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

             INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2007

                                    _______

                    October 16, 2007.--Ordered to be printed

                                    _______

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

                                  R E P O R T

                             [To accompany S. 1200]

        The Committee on Indian Affairs, to which was referred the
    bill (S. 1200) to amend the Indian Health Care Improvement Act
    to revise and extend that Act, having considered the same,
    reports favorably thereon without amendment and recommends that
    the bill do pass.

                                    Purpose

        The purpose of the Indian Health Care Improvement Act
    Amendments of 2007 (S. 1200) is to reauthorize the Act to
    maintain and improve the Indian health care delivery system.
    This legislation is intended to raise the health status of
    American Indians and Alaska Natives\1\ to the highest possible
    level in accordance with Healthy People 2010.\2\
    ---------------------------------------------------------------------------
        \1\The original Act defines the term ``Indian'' to include Indians
    and Alaska Natives.
        \2\Healthy People 2010 is the major health agenda for the Nation.
    ``It is a statement of national health objectives designed to identify
    the most significant preventable threats to health and to establish
    national goals to reduce these threats.'' U.S. Department of Health and
    Human Services, www.healthypeople.gov.
    ---------------------------------------------------------------------------
        S. 1200 builds upon current law to set forth policies,
    programs and procedures designed to address health care
    deficiencies in Indian and urban Indian communities, and to
    streamline service delivery to those communities. In addition,
    S. 1200 addresses the health problems and associated socio-
    economic conditions in Native American communities by
    authorizing the Indian Health Service (IHS) and tribes to adopt
    current health industry ``best practices.''

                                   Background

        Enacted in 1976, the Act established the first
    comprehensive framework for the delivery of health care
    services for Native people, including various health programs,
    projects, and facilities. The Act was last reauthorized in
    1992, and authorized funding for various programs through
    Fiscal Year 2000. Public Law 106-568 included a simple
    extension of the Act's authority through FY 2001. Congress has
    continued to fund programs under the Act through the general
    permanent authority under the Snyder Act (25 U.S.C. 13).

                          THE REAUTHORIZATION PROCESS

        The work on the latest reauthorization of the Indian Health
    Care Improvement Act began in 1999. Bills have been introduced
    since the 106th Congress\3\ to provide numerous improvements
    and updates to current law, many of which are contained in S.
    1200.
    ---------------------------------------------------------------------------
        \3\S. 2526 (106th Congress), S. 212 (107th Congress), S. 556 (108th
    Congress), S. 1200 and S. 4122 (109th Congress).
    ---------------------------------------------------------------------------
        In June, 1999, the Director of the IHS convened a National
    Tribal Steering Committee on the Reauthorization of the Indian
    Health Care Improvement Act (NSC), which was comprised of
    tribal leaders and representatives from Indian health
    organizations to facilitate the Act's reauthorization. The NSC
    held a series of meetings in 1999, during which extensive
    discussions were held between the NSC and Department of Health
    and Human Services (DHHS) officials. The NSC also received
    technical assistance from DHHS officials during these meetings.
        The NSC set out to craft a comprehensive legislative
    proposal that would reflect a consensus of the Indian tribes.
    With over 560 federally-recognized Indian tribes, each with
    unique histories, cultures, locations and needs, the NSC faced
    serious challenges. Despite the many differences, they
    coalesced around a draft document which formed the basis of the
    bills introduced, S. 2526 (106th Congress) and S. 212 (107th
    Congress). Neither bill was enacted.
        During the 108th Congress, the Committee, the NSC and the
    Administration engaged in extensive negotiations over
    reauthorization issues, but action on a final version of that
    Congress' bill, S. 556, did not occur before the conclusion of
    the 108th Congress. Several recommendations developed during
    these negotiations were incorporated into S. 1057, which was
    introduced in the 109th Congress.
        In the first session of the 109th Congress, the Indian
    Affairs Committee favorably reported an amendment in the nature
    of a substitute to S. 1057. In the ensuing months, the
    Committee engaged in discussions with the Administration--not
    only DHHS, but also the Department of Justice. Changes based on
    these discussions were made in an amendment in the nature of a
    substitute to S. 1057. In addition, the Committee worked
    extensively with the Senate Finance Committee on provisions in
    the jurisdiction of that committee, which were separately
    reported out by the Finance Committee on June 8, 2006, as S.
    3524, and incorporated in to the amendment in the nature of a
    substitute to S. 1057. Comments were also received from the
    Senate Health, Education, Labor and Pensions Committee, on
    provisions over which that Committee maintains an interest, and
    many were incorporated. A new bill, based on the amendment in
    the nature of a substitute, was introduced as S. 4122 on
    December 8, 2006, the last day of the second session of the
    109th Congress. No further consideration of that measure
    occurred.

                     OVERVIEW OF INDIAN HEALTH CARE HISTORY

        The history of the Federal responsibility for Indian health
    care is quite extensive and well-documented in numerous
    sources, including past Senate reports accompanying prior
    legislation, (see, e.g., Senate Report Nos. 94-133, 102-392,
    108-411 and 109-222).
        Based on the U.S. Constitution, treaties, statutes and the
    historical, political and legal relationship with the Indian
    tribes, the United States has assumed a trust responsibility
    for the provision of health care to Indian people. Those laws
    and relationships serve as the backdrop for the government-to-
    government relationship.
        Extensive research indicates that the health of Indians
    deteriorated after contact with the European colonists, as the
    aboriginal inhabitants had no natural immunities to the
    diseases carried by the new arrivals. Decades later, when
    Federal policy forced the Indians to relocate from their
    homelands and settle on reservations and, in many cases,
    prohibited the conduct of traditional practices--including
    traditional healing--the health of Indians continued to
    plummet. Thus, health care became a particularly significant
    element of the treaties and other agreements between the Indian
    tribes and the United States.
        During the early 1800s, the health care provided was little
    more than vaccinations for the Indians around federal military
    posts in order to protect the soldiers and non-Indians from the
    possibility that Indians might spread diseases. During the late
    1800s, physicians and hospitals were added to the reservations
    and other outposts. Mention of the provision of health care was
    included in treaties. For example, the Treaty with the
    Chippewa, Red Lake and Pembina Bands, of 1864, stated in
    Article 4,

              The United States also agree[s] to furnish said bands
            of Indians, for the period of fifteen years, one
            blacksmith, one physician, one miller, and one farmer;
            and will also furnish them annually, during the same
            period, with fifteen hundred dollars' worth of iron,
            steel, and other articles for blacksmithing purposes,
            and one thousand dollars for carpentering, and other
            purposes (emphasis added).\4\
    ---------------------------------------------------------------------------
        \4\Charles J. Kappler, Indian Affairs: Laws & Treaties, Vol. II, at
    861.

        With respect to federal agencies overseeing the
    responsibility for Indian health, the task was first assigned
    to the War Department in 1803, then to the Interior Department
    in 1849, before finally being transferred to the Department of
    Health, Education and Welfare (DHEW), the predecessor of the
    DHHS, in 1955. The Division of Indian Health within DHEW had
    initial responsibility for Indian health before eventually
    being renamed the Indian Health Service.\5\
    ---------------------------------------------------------------------------
        \5\Report on Indian Health by Task Force Six: Indian Health in the
    Final Report to the American Indian Policy Review Commission (Final
    Report) at 32.
    ---------------------------------------------------------------------------
        In 1921, Congress enacted the Snyder Act (25 U.S.C. 13), to
    provide for permanent appropriations authority for Indian
    health programs and services. However, the Snyder Act did not
    provide meaningful standards by which to measure progress in
    Indian health status or other improvements in services.
        The lack of standards in the Snyder Act and other organized
    efforts led the American Indian Policy Review Commission to
    conclude in 1976 that

            there [was] no clear overall direction or policy for
            implementation of the various programs. As a result,
            the Indian Health Services operates primarily an
            emergency and crisis oriented service. . . . This has
            resulted in increased prevalence of certain health
            deficiencies which are virtually unknown in the general
            population.\6\
    ---------------------------------------------------------------------------
        \6\Id. at 12.

        Shortly after the responsibility for Indian health was
    transferred to DHEW, Congress passed the Indian Sanitation
    Facilities and Services Act, 42 U.S.C. 2004, which authorized
    the IHS to provide sanitation facilities to Indian communities.
    These sanitation facilities were critical to eliminating many
    health maladies associated with the lack of proper sanitation,
    such as dysentery and infectious hepatitis.
        The administration of Indian health had initially been
    managed in a piecemeal approach, then ultimately was placed
    within the IHS, an agency of the DHHS. Based on that history
    and in fulfillment of the special trust obligation to Indian
    people, Congress passed the Indian Health Care Improvement Act
    to provide coordinated programs and meaningful direction in
    Indian health care administration. The underlying
    responsibility to provide health care did not originate with
    the Act; rather, the Act was passed after Congress recognized
    that a sea-change in administration and management was needed
    to ensure improvements were achieved in Indian health status
    and services.

                       THE PRE-IHCIA INDIAN HEALTH SYSTEM

        At the time of passage of the Act in 1976, the information
    on Indian health painted a stark portrait of existence in
    Indian communities. Senate Report No. 94-133 accompanying S.
    522, the Indian Health Care Improvement Act of 1976, which was
    signed into law as Public Law 94-437, indicated that the ``vast
    majority of Indians still live in an environment characterized
    by inadequate and understaffed health facilities, improper or
    nonexistent waste disposal and water supply systems, and
    continuing dangers of deadly or disabling diseases.''\7\
    ---------------------------------------------------------------------------
        \7\S. Rep. No. 94-133, at 36 (1976).
    ---------------------------------------------------------------------------
        Health Status. These conclusions were based upon the
    statistics at the time. For example, the ``incidence of
    tuberculosis for Indians and Alaska Natives [was] 7.3 times
    higher than the rate for all citizens of the United States. . .
    . [T]he suicide rate . . . [was] approximately twice as high as
    in the total U.S. population.''\8\ Also troubling was the
    infant mortality rate for Indian babies, which was
    significantly higher than the national average.\9\
    ---------------------------------------------------------------------------
        \8\Id.
        \9\Id.
    ---------------------------------------------------------------------------
        Health Professionals. Compounding the low health status
    were the difficulties in recruiting and retaining qualified
    health professionals--Indian health professionals, in
    particular--to work in the Indian communities. The available
    information indicated that out of 500 doctors in the Indian
    Health Service, only 3 were Indian.\10\ Overall, ``in 1975,
    there were only 72 American Indian physicians to serve the
    needs of 1,000,000 American Indians, most of whom lived on
    Reservations.''\11\ Likewise, only half of the number of
    pharmacists needed was employed in these Indian
    communities.\12\
    ---------------------------------------------------------------------------
        \10\Id., at 55.
        \11\Headlands Indian Health Careers, Program History, available at
    http://www.headlands.ouhsc.edu/history.asp.
        \12\S. Rep. No. 94-133, at 42 (1976).
    ---------------------------------------------------------------------------
        Health Facilities. The conditions and availability of
    health facilities did not fare any better. A significant number
    of the existing facilities were over twenty years old. Many
    others were ``old one-story, wooden buildings with inadequate
    electricity, ventilation, insulation and fire protection
    systems, and of such insufficient size as to jeopardize the
    health and safety of their occupants.''\13\ The Joint Committee
    on Accreditation of Hospitals (JCAHO) found that ``only 24 of
    the 51 existing IHS hospitals'' met accreditation standards and
    ``two-thirds [were] obsolete and that 22 need[ed] complete
    replacement.''\14\
    ---------------------------------------------------------------------------
        \13\Id. at 36-37.
        \14\Id., at 37.
    ---------------------------------------------------------------------------
        Funding. The funding available for the provision of health
    services to Indians also revealed significant disparities. For
    example, ``[p]er capita expenditures for Indian health purposes
    [were] 25 percent below per capita expenditures for health care
    in the average American community.''\15\
    ---------------------------------------------------------------------------
        \15\Id.
    ---------------------------------------------------------------------------
        Accordingly, the goals of the Act held great promise for
    the advancement of Indian health by improving the direction in
    programs and access to other programs, such as Medicare and
    Medicaid.

                          CURRENT INDIAN HEALTH SYSTEM

        Since 1976, significant improvements have been made in the
    programs and funding levels authorized for Indian health
    through the Act and the amendments thereto. Yet, a comparison
    of historic statistics with current status indicators shows
    that, while real progress has been made, significant
    disparities still persist.
        Indian Health Status. The Indian Health Service report
    2000-2001 Trends in Indian Health indicates the age-adjusted
    death rates for American Indians and Alaska Natives for 1996-
    1998 was five times the rate for U.S. all-races in 1997.\16\
    Despite a decrease of 64% over a period spanning 1972 to 1999,
    Indian infant mortality rates still remained 24% higher than
    other U.S. populations.\17\ Other Indian mortality rates far
    exceeded the mortality rates of other U.S. populations for
    causes including alcoholism (638%), diabetes mellitus (291%),
    unintentional injuries (215%), pneumonia and influenza (67%),
    gastrointestinal disease (38-40%) and heart disease (20%).
    ---------------------------------------------------------------------------
        \16\U.S. Department of Health and Human Services, Indian Health
    Service, 2000-2001 Trends in Indian Health, at 68.
        \17\U.S. Department of Health and Human Services, Indian Health
    Service, 2000-2001 Trends in Indian Health, at 162.
    ---------------------------------------------------------------------------
        Even during the short period of 1997 to 2004, the
    ``prevalence of diagnosed diabetes increased by 47 percent in
    all major regions (all ages) served by the Indian Health
    Service.'' The most alarming increase, however, has occurred
    among younger American Indians and Alaska Natives, with a 160
    percent increase from 1990-2004 for young adults aged 25-34
    years, and a 128 percent increase for adolescents aged 15-19
    years from 1990-2004.\18\
    ---------------------------------------------------------------------------
        \18\U.S. Department of Health and Human Services, Indian Health
    Service, Fiscal Year 2008, Justification of Estimates for
    Appropriations Committees, at CJ-147.
    ---------------------------------------------------------------------------
        Recent information also indicates that suicide rates among
    youth in Indian Country are predominately higher than for non-
    Indian youth. In 2005, the Committee held two hearings on the
    issue of Indian youth suicide. A field hearing was held in
    Bismarck, N.D. on May 2, 2005, and an oversight hearing was
    held in Washington, D.C. on June 15, 2005. During the second
    session of the 109th Congress, on May 17, 2006, the Committee
    held an oversight hearing on suicide prevention programs and
    their application in Indian Country.
        According to national data for 2002, suicide was the second
    leading cause of death for Indians of both sexes in the 15-34
    year age range, and the fourth leading cause of death for both
    sexes in the 10-14 year age range. On the reservations of the
    Northern Great Plains (States of North and South Dakota, Iowa,
    Minnesota and Nebraska), the rate of Indian youth suicide is up
    to 10 times higher than it is elsewhere in the country. At
    several Indian health facilities, the demand for mental health
    care outstripped capacity.\19\ In at least one facility, the
    mental health services were to be cut by 20% in FY 2005 because
    funding had been depleted.\20\
    ---------------------------------------------------------------------------
        \19\United States Government Accountability Office, Report to the
    Committee on Indian Affairs, U.S. Senate, Indian Health Service: Health
    Care Services Are Not Always Available to Native Americans, GAO Report
    No. GAO-05-789, (August, 2005) at 18.
        \20\GAO Report No. GAO-05-789 at 18.
    ---------------------------------------------------------------------------
        Another alarming and growing problem arising in Indian
    communities is the use of methamphetamines. The Committee held
    an oversight hearing on the problem of methamphetamine in
    Indian Country on April 5, 2006. According to the National
    Survey on Drug Use and Health, the past-year use rate during a
    2002-2004 survey period among American Indians and Alaska
    Natives aged 12 and older is higher than every other population
    except Native Hawaiians or other Pacific Islanders and youth
    reporting two or more races.\21\
    ---------------------------------------------------------------------------
        \21\U.S. Department of Health and Human Services, Substance Abuse
    and Mental Health Services Administration, Office of Applied Studies,
    National Survey on Drug Use and Health, The NSDUH Report, September 16,
    2005, http://oas.samhsa.gov/2k5/meth/meth.htm.
    ---------------------------------------------------------------------------
        Health Facilities. According to the Indian Health Service's
    FY 2008 budget request, the IHS health care facilities system
    is made up of 163 Service Units (63 IHS, 100 tribal); 48
    Hospitals (33 IHS, 15 tribal); and 603 Ambulatory Care Centers
    (92 IHS and 511 tribal) (consisting of Health Centers, School
    Health Centers, Health Stations and Alaska Village
    Clinics).\22\
    ---------------------------------------------------------------------------
        \22\U.S. Department of Health and Human Services, Indian Health
    Service, Fiscal Year 2008, Justification of Estimates for
    Appropriations Committees, at CJ-251.
    ---------------------------------------------------------------------------
        According to the IHS Health Facilities Construction
    Priority System, the estimated unfunded total cost to meet the
    need was nearly $3.5 billion as of FY 2008.\23\ In addition,
    the backlog for the maintenance and improvement needs of
    current facilities was estimated at $408,956,000.\24\
    ---------------------------------------------------------------------------
        \23\U.S. Department of Health and Human Services, Indian Health
    Service, chart of Health Care Facilities FY 2009 Planned Construction
    Budget (March 30, 2007).
        \24\U.S. Department of Health and Human Services, Indian Health
    Service, Fiscal Year 2008, Justification of Estimates for
    Appropriations Committees, at CJ-164.
    ---------------------------------------------------------------------------
        However, on the positive side, ``All IHS and Tribally-
    operated hospitals are accredited by the Joint Commission on
    Accreditation of Healthcare Organizations (JCAHO) or certified
    by the Centers for Medicare and Medicaid Services (CMS).''\25\
    ---------------------------------------------------------------------------
        \25\Id., at CJ-167.
    ---------------------------------------------------------------------------
        In addition, since the Indian Sanitation Facilities and
    Services Act, Public Law 86-121, codified at 42 U.S.C. 2004,
    was passed in 1959, ``over 270,000 Indian homes have been
    provided sanitation facilities'' which served to reduce ``[t]he
    gastroenteric and post-neonatal death rates among the Indian
    people . . . primarily because of the increased prevalence of
    safe drinking water supplies and sanitary waste disposal
    systems.''\26\ The IHS noted that ``[i]n 1955, more than 80
    percent of American Indians and Alaska Natives were living in
    homes without essential sanitation facilities.''\27\ The age-
    adjusted gastrointestinal death rate was ``15.4 per 100,000
    population. . . . 4.3 times higher than that for all other
    races in the United States.''\28\ But by 1995, that death rate
    was reduced to 1.7 per 100,000, although that 1995 rate is
    still 40% higher than the rate for all races in the United
    States.\29\
    ---------------------------------------------------------------------------
        \26\U.S. Department of Health and Human Services, Indian Health
    Service. The Sanitation Facilities Construction Program of the Indian
    Health Service, Public Law 86-121, Annual Report for 2005, at 1.
        \27\Id., at 21.
        \28\Id.
        \29\Id.
    ---------------------------------------------------------------------------
        In FY 2005, approximately $132 million was appropriated for
    sanitation facilities construction, of which $91.7 million was
    appropriated to the Indian Health Service and more than $40.4
    million came from other Federal agencies and non-Federal
    sources such as tribes and state agencies.\30\ IHS estimated
    that in FY 2005, the Sanitation Construction Program provided
    sanitation facilities to a total of 24,072 homes.\31\ However,
    the total estimated costs needed to address the sanitation
    deficiencies in existing homes as of the end of FY 2006 totaled
    over $2.2 billion, with projects considered economically
    feasible totaling $1 billion. There were more than 155,000
    Indian and Alaska Native homes in need of sanitation
    facilities, including more than 38,000 which are without
    potable water.\32\
    ---------------------------------------------------------------------------
        \30\U.S. Department of Health and Human Services, Indian Health
    Service. The Sanitation Facilities Construction Program of the Indian
    Health Service, Public Law 86-121, Annual Report for 2005, at 5.
        \31\Id.
        \32\U.S. Department of Health and Human Services, Indian Health
    Service, Justification of Estimates for Appropriations Committees for
    Fiscal Year 2008, at CJ-170.
    ---------------------------------------------------------------------------
        Health Professionals. The number of Indian health
    professionals has increased since the Act was first signed into
    law. According to the latest Census information, there were
    over 1,300 Indian physicians and surgeons and over 10,000
    Indian registered nurses.\33\ These numbers suggest that the
    incentives in the Act have assisted in increasing these
    numbers. However, vacancy rates for key health professionals
    indicate that a substantial need still exists for qualified
    health professionals in the Indian health system. The December,
    2006, vacancy rates for health professions with the greatest
    shortfalls consist of Dentists (32%), Optometrists (12%),
    Nurses (17%), and Pharmacists and Physicians (both 12%).\34\
    ---------------------------------------------------------------------------
        \33\U.S. Census Bureau, American FactFinder, Census 2000 Summary
    File 4, Table PCT86. The numbers are for individuals reporting only the
    American Indian and Alaska Native race.
        \34\U.S. Department of Health and Human Services, Indian Health
    Service, Justification of Estimates for Appropriations Committees for
    Fiscal Year 2008, at CJ-125.
    ---------------------------------------------------------------------------
        Types and Level of Services. The IHS, tribal and urban
    Indian health programs provide an array of basic medical,
    dental and vision services, including inpatient care, and
    routine and emergency ambulatory care; and medical support
    services including laboratory, pharmacy, nutrition, diagnostic
    imaging, medical records, physical therapy, etc.,\35\ as well
    as other preventive, clinical and environmental health
    services. When these services are not available at their
    facilities, IHS, tribal and urban programs purchase medical
    care and urgent care services through the Contract Health
    Services program.
    ---------------------------------------------------------------------------
        \35\U.S. Department of Health and Human Services, Indian Health
    Service, Fiscal Year 2008, Justification of Estimates for
    Appropriations Committees, at CJ-71.
    ---------------------------------------------------------------------------
        Even though basic services may be available at an Indian
    health facility, access to these services is not assured. In
    its study on the availability of health services to Indians in
    August, 2005, the Government Accountability Office (GAO) found
    that Indian patients often had to wait more than 30 days--in
    some cases two to six months--between setting the appointment
    for services and receiving the services, a time frame ``in
    excess of standards and goals identified in other federally
    operated health service delivery systems.''\36\ Moreover,
    ``[t]he most frequent gaps were for services aimed at the
    diagnosis and treatment of medical conditions that caused
    discomfort, pain, or some degree of disability but that were
    not emergent or acutely urgent.''\37\ For example, in some
    cases, adult Indian patients ``could wait as long as 120 days
    to get approval for eyeglasses.''\38\ According to one tribal
    official interviewed by the GAO, these situations create an
    environment in which Indian patients become demoralized and may
    wait until their condition becomes ``an emergency that required
    a higher level of treatment.''\39\
    ---------------------------------------------------------------------------
        \36\GAO Report No. GAO-05-789, at 15.
        \37\Id., at 19.
        \38\Id.
        \39\GAO Report No. GAO-05-789, at 16.
    ---------------------------------------------------------------------------
        The Committee is deeply concerned with the GAO's findings
    and its conclusions that the disturbing result of these gaps
    are ``diagnosis or treatment delays that exacerbate[] the
    severity of a patient's condition and create[] a need for more
    intensive treatment.''\40\ The Committee is further concerned
    that these gaps increase the costs of health care and diminish
    the potential for prevention efforts.
    ---------------------------------------------------------------------------
        \40\Id., at 21.
    ---------------------------------------------------------------------------
        The Committee appreciates the Administration's efforts in
    promoting prevention as a key to reducing health care costs,
    but believes a much greater effort is needed to reduce gaps in
    health services to Indians. Improvements are needed in all
    areas of the Indian health care system to ameliorate problems
    and delays in service delivery. The improvements outlined in S.
    1200 for programs and policies, provisions in S. 1200 which
    would be new to the Act, including services for home- and
    community-based care, youth suicide prevention and convenient
    care services, and the National Bipartisan Commission on Indian
    Health Care study on the delivery of federal health care
    services to Indians are all designed to help address these
    problems.

                     THE INDIAN HEALTH CARE IMPROVEMENT ACT

        In passing the Indian Health Care Improvement Act of 1976,
    Congress set forth ambitious goals for improving the health of
    Indians, including encouraging Indian participation in ``the
    planning and management'' of health services (25 U.S.C.
    1601(b)). The Act ``would provide the direction and financial
    resources to overcome the inadequacies in the existing Federal
    Indian health care program.''\41\ These goals built upon the
    foundation laid in President Nixon's 1970 ``Special Message to
    the Congress on Indian Affairs.''\42\ In his ``Special
    Message,'' President Nixon declared that ``[t]he time ha[d]
    come to break decisively with the past and to create the
    conditions for a new era in which the Indian future is
    determined by Indians acts and Indian decisions.''\43\
    ---------------------------------------------------------------------------
        \41\Senate Report No. 94-133, at 13.
        \42\President's Special Message to Congress on Indian Affairs, 213
    Pub. Papers 564 (July 8, 1970).
        \43\President's Special Message to Congress on Indian Affairs, 213
    Pub. Papers 565 (July 8, 1970).
    ---------------------------------------------------------------------------
        Breaking decisively with the past meant a radical change in
    health care delivery, beginning with the administration of the
    programs and policy-making. Placing administrative and
    decision-making authority in the hands of Indian tribal
    governments, rather than solely in the agency's hands, was both
    a fundamental and logical change in the approach in health care
    delivery. Reconfirming the tribes' authority to administer
    health programs, however, took several years to achieve.\44\
    ---------------------------------------------------------------------------
        \44\See, e.g., U.S. General Accounting Office, now, U.S. Government
    Accountability Office, Report to the Chairman, Select Committee on
    Indian Affairs, U.S. Senate, Indian Health Service, Contracting under
    the Indian Self-Determination Act, GAO Report No. GAO/HRD-86-99,
    September, 1986.
    ---------------------------------------------------------------------------
        Today, nearly half of the IHS budget is administered
    through tribal contracts or compacts under the Indian Self-
    Determination and Education Assistance Act of 1976 (ISDEAA), 25
    U.S.C. 450 et seq. Title I contracts and Title V compacts total
    more than $1.6 billion. The IHS currently administers contracts
    and Annual Funding Agreements with 245 tribes or tribal
    organizations, and 72 compacts and 93 funding agreements with
    322 tribes.\45\ These numbers not only reflect congressional
    policy of promoting tribal self-determination, but generate a
    higher level of cooperation among Indian health providers.
    ---------------------------------------------------------------------------
        \45\U.S. Department of Health and Human Services, Indian Health
    Service, Fiscal Year 2008, Justification of Estimates for
    Appropriations Committees, at CJ-258.
    ---------------------------------------------------------------------------

                   GENERAL PRINCIPLES IN THE REAUTHORIZATION

        During the reauthorization process, a critical assessment
    of the Act was undertaken by the Committee and the Indian
    health community and several basic principles emerged. The
    history of Indian health and the interplay between the ISDEAA
    and the Act are key considerations in the development of sound
    Indian health policy.
        Self-Determination. Since self-determination was declared
    to be the new direction in Federal Indian policy, tribal
    participation has significantly contributed to improving both
    health and other services for Indian people.\46\ Meaningful
    participation by tribes in administering programs through
    contracting or compacting has been a principal means of
    implementing the self-determination policy.
    ---------------------------------------------------------------------------
        \46\See e.g., National Indian Health Board, Tribal Perspectives on
    Indian Self-Determination and Self-Governance in Health Care
    Management, 1998.
    ---------------------------------------------------------------------------
        However, simply administering a program designed and handed
    down by the agency does not accomplish the vision embodied in
    self-determination. Indian and Alaska Native participation is
    critical in the development of the framework of these programs
    and services. Tribal self-determination involves tribes
    designing or modifying programs, as well as formulating new
    ideas, concepts and methodologies of how those programs or
    services should be delivered to their own communities.
        Negotiated Rulemaking and Consultation. Such participation
    means appreciable engagement between the agency and Indian
    tribes, and numerous tools have successfully increased that
    involvement. For example, negotiated rulemaking under the
    Administrative Procedures Act has been found to be useful in
    several initiatives such as education, housing and Self-
    Governance.\47\
    ---------------------------------------------------------------------------
        \47\See, e.g., No Child Left Behind Act, Pub. L. 107-110, 25 U.S.C.
    2001, et seq.; Native American Housing Assistance and Self-
    Determination Act, Pub. L. 104-330, 25 U.S.C. 4116; Indian Self-
    Determination and Education Assistance Act, Pub. L. 106-477, 25 U.S.C.
    458aa-16.
    ---------------------------------------------------------------------------
        The Committee has received testimony from tribal
    participants in negotiated rulemaking that ``true understanding
    among tribes and with IHS is achieved''\48\ through that
    process. That ``true understanding'' is consistent with the
    Committee's desire to foster consensus-building and reduce
    obstacles that negatively impact health care service delivery,
    as well as to carry out the government-to-government
    relationship between Indian tribes and the federal government.
    ---------------------------------------------------------------------------
        \48\Indian Health Care Improvement Act Amendments of 2005: Joint
    Hearing on S. 1057 Before the Senate Committee on Indian Affairs and
    Senate Committee on Health, Education, Labor and Pensions, 109th Cong.,
    1st Session, S. Hrg. 109-162 at 725 (July 14, 2005) (statement of Don
    Kashaveroff, President, Seldovia Village Tribe).
    ---------------------------------------------------------------------------
        The Administration has expressed concerns about the time
    and resource constraints involved in negotiated rulemaking. The
    Committee strongly supports fiscal accountability and decreased
    bureaucracy, but believes that the long-term benefits of
    negotiated rulemaking more than justify the costs which may be
    required in the short-term.
        The Committee believes that the Indian tribal and urban
    health providers--as first responders in the health system--
    should be directly involved in developing health programs and
    the regulations that affect their service populations. Tribal
    involvement in rulemaking not only leads to a more informed
    rule, but it fosters tribal support. In addition, negotiated
    rulemaking can save costs to all parties in the long run. By
    building a higher level of consensus in the regulations, the
    IHS lowers the potential for legal challenges to the rules and
    associated litigation costs. The Committee favors consensus-
    building over litigation and encourages this long-term view.
    The concerns are further abated by the limited number of
    program criteria or requirements under the Act which are
    subject to negotiated rulemaking. Section 802 outlines the
    scope for negotiated rulemaking which is limited to Titles II
    (except for section 202) and VII, a few sections in Title III,
    and section 807.
        Besides negotiated rulemaking, the Committee has favored
    consultation with tribes as another tool to increase tribal
    participation, but has generally left the manner or method of
    consultation to the discretion of the Secretary.
        For example, the ISDEAA simply requires an annual
    consultation on the budget. However, the Secretary has in the
    past implemented a rigorous regional and national schedule for
    budget consultation, holding the 9th Annual HHS Tribal Budget
    Formulation and Policy Consultation Session in Washington, DC,
    March 28 and 29, 2007.\49\
    ---------------------------------------------------------------------------
        \49\See www.hhs.gov/iga/tribal.
    ---------------------------------------------------------------------------
        The Committee recognizes that the Administration has made
    efforts to involve Indian tribes in decision-making through the
    consultation policy issued by the DHHS.\50\ The Committee also
    recognizes that the Department's policy has attempted to
    address a wide variety of matters affecting Indian communities.
    However, the Committee is concerned that the scope of the
    Department policy may not fully encompass all critical matters
    for which the Committee believes consultation should be used,
    or that comments received are fully considered.
    ---------------------------------------------------------------------------
        \50\U.S. Department of Health and Human Services, Department Tribal
    Consultation Policy, January, 2005, available at www.hhs.gov/ofta/docs/
    FnlCnsltPlcywl.pdf.
    ---------------------------------------------------------------------------
        Such matters involve the development of program eligibility
    or criteria, or relate to specific tribes, Indian population
    groups (e.g., women) or to special tribal history, customs, or
    practices. Consequently, remaining committed to promoting
    tribal input by institutionalizing consultation, the Committee
    has provided for robust consultation requirements in several
    key areas, while leaving the manner of consultation to
    Secretarial discretion.
        Flexibility. In addition, the Committee believes that less
    bureaucracy and more flexibility are needed to tailor programs
    or services to address local community health needs.\51\ The
    Committee is pleased that the Administration has joined in
    supporting flexibility and new approaches to health care, and
    expanding the range of options of health services.\52\
    ---------------------------------------------------------------------------
        \51\Flexibility also eliminates the need to identify each and every
    program that may be administered by IHS, the tribal or urban programs
    (e.g., the definition of ``health professions'' does not identify every
    profession that may be authorized). Many of the decisions or priorities
    are left to the Indian health providers to determine to implement as
    needed. The Committee is aware that the IHS, Indian tribes and urban
    programs engage in extensive budget consultations, sometimes two years
    in advance of implementation, where programs and professions to
    emphasize for scholarships is discussed.
        \52\S. Hrg. 109-162 at 589 (statement of Dr. Grim, Director, U.S.
    Department of Health and Human Services, Indian Health Service).
    ---------------------------------------------------------------------------
        However, in the course of negotiating this legislation, the
    Administration has repeatedly indicated its preference to
    change mandatory programs to discretionary ones to meet
    budgetary constraints and to give the Secretary maximum
    flexibility.\53\ The Committee has accommodated these
    principles based on the understanding that Indian tribes would
    also be accorded the same flexibility under the Act and the
    ISDEAA.
    ---------------------------------------------------------------------------
        \53\Id., at 596, and S. Hrg. 110-53 at 38 (March 8, 2007)
    (statement of Admiral John Agwunobi).
    ---------------------------------------------------------------------------
        The Committee has been informed that, in the past, the
    Indian tribes had been foreclosed from implementing programs
    that the agency did not actually implement either under the Act
    or the Snyder Act, 25 U.S.C. 13. Simple program authorizations
    under the Act and the Snyder Act were deemed insufficient to
    allow the Indian tribes to administer the programs even under
    the redesign provisions of the ISDEAA.
        It is the Committee's intent, however, that simple
    authorizations are sufficient to enable tribes to implement
    programs, even if the Federal agency chooses not to, provided
    all other applicable provisions of the Act, the Snyder Act and
    the ISDEAA are met. The Committee believes that this
    interpretation is necessary to enable Indian tribes to meet the
    needs of their communities and required, if the Secretary is to
    experience the flexibility desired.
        Oversight and Reporting. In the past, the Committee has
    been reluctant to eliminate certain mandates, such as those
    requiring studies. For example, many studies and reports
    mandated by the 1976 Act have never been completed. These
    studies were intended to provide insight into the
    accomplishments and challenges in Indian health and to assist
    the Congress in seeking new approaches to service delivery. The
    Committee is troubled that the health status of Indians
    reflects many of the same problems it did in 1976, and that
    several mandated studies, reports and programs in current law
    have been disregarded.
        Consequently, the Committee has included in S. 1200
    provisions which will establish a National Bipartisan
    Commission on Indian Health Care to thoroughly review
    opportunities for improvement of the Indian health care system.
    During the 108th Congress, the bill to reauthorize the Act, S.
    556, contained provisions requiring the Bipartisan Commission
    to study the potential of funding Indian health as an
    entitlement. Based on the Administration's recommendations
    offered during the 108th Congress, the Committee modified the
    Commission's objectives to what is now included in S. 1200.
        In addition, the Committee has included authorization of
    the Native American Health and Wellness Foundation, provisions
    to promote the mission of IHS in improving Indian health. This
    Foundation is not a substitute for the federal obligation to
    provide health services to Indians, but is intended to
    complement the federal obligation in ways in which the United
    States has fallen short.
        While much discretion and flexibility is provided to the
    IHS throughout S. 1200, the Committee must preserve the
    necessary mechanisms to fulfill its oversight function. The
    primary means is through active reporting requirements by the
    Secretary. Congress simply cannot leave unfettered the
    operations of these important programs without appropriate
    assurances that Indian people are being served consistent with
    Congressional intent and priorities. Moreover, Congress should
    be informed of how and when these programs meet--or fall short
    of meeting--the basic health needs of Indian people.

                                 KEY PROVISIONS

        Several key improvements to the Act contained in S. 1200
    are particularly noteworthy:
        Health Professions. Difficulties in recruiting and
    retaining qualified health professionals have long been
    recognized as a significant factor impairing Indians' access to
    health care services.\54\ Noting that many Indian communities
    are often in remote locations and lack adequate housing and
    educational and recreational opportunities for employees and
    their families,\55\ the GAO reported that some critical
    positions such as for pharmacists and dentists remained vacant
    for several years in some locations.\56\
    ---------------------------------------------------------------------------
        \54\See also GAO Report No. GAO-05-789, at 4.
        \55\GAO Report No. GAO-05-789, at 4.
        \56\Id.
    ---------------------------------------------------------------------------
        The provisions in Title I address the health professional
    shortage in Indian communities. Congress specifically included
    these provisions in 1976 because the existing programs to
    improve manpower capabilities were woefully inadequate or
    completely unsuitable for Indian health providers and
    communities.\57\
    ---------------------------------------------------------------------------
        \57\Senate Report No. 94-133, at 55-57.
    ---------------------------------------------------------------------------
        The programs existing in 1976 did ``not link the recipients
    [of scholarships] directly to the Indian Health Service,'' were
    ``not designed to recruit and support Indians,'' and were too
    limited in the ``category of health professionals'' supported
    by these programs.\58\
    ---------------------------------------------------------------------------
        \58\Id., at 55-56.
    ---------------------------------------------------------------------------
        Consequently, Congress developed a new approach and the IHS
    scholarship program was born. Fears of duplication were quickly
    disproven by the obvious need for and success of these programs
    in filling vacancies and returning Indian health professionals
    to the Indian communities. Today, the program has expanded to
    include a wide variety of health professions as determined by
    the priorities set by the IHS and the Indian tribes. Besides
    the scholarships, the program also now includes loan
    repayments, a tribal scholarship program, and bonus incentive
    payments.
        These programs specifically target the needs of the Indian
    health system. For example, the scholarship priorities are
    developed through a year-long consultation process wherein the
    IHS sends the program information and request for priority to
    each Indian tribe and the tribal education and health programs.
    The comprehensive list is developed based on the IHS and tribal
    health professional projected needs, vacancies and available
    positions. By focusing on the specific needs of Indian
    communities, the Committee believes that this approach has
    significantly improved Indian health.
        Targeting the specific needs of the Indian health system
    has become the hallmark of the Indian health professional
    policy. Likewise, a continuous and seamless transitional
    approach also is a key policy component in increasing the
    number of Indian health professionals. The Committee strongly
    encourages the Secretary to evaluate all opportunities to
    improve the chances of success for Indian health professionals,
    including obtaining the licenses or certifications necessary
    for providing health care services. The Committee has been made
    aware of the need to increase the number of licensed health
    professionals in the Indian health system and included
    provisions in S. 1200 to address that need. S. 1200 provides
    for portability of current licenses for tribal health
    professionals consistent with other Federal health licensing
    provisions. In addition, S. 1200 authorizes programs to enhance
    and facilitate enrollment in and completion of courses of study
    in health professions.
        The Committee believes that the Title I programs should
    fully equip the Indian student trainees with the tools needed
    to transition into the health profession, including
    successfully completing all courses of study and passing the
    required licensing or board examinations. In addition, the
    Committee expects that the IHS would also ensure that
    scholarship recipients are provided every opportunity to
    fulfill their service obligations, including technical
    assistance in understanding their obligations.
        The remedial programs, scholarships, grants, externships,
    service obligations and advanced training established in Title
    I are all designed to provide seamless opportunities for
    successfully recruiting and training Indians for health
    professions. As part of the long-term view of Indian health
    professions, the Committee believes continuity is necessary in
    administering the Title I programs.
        The incentives fostered by scholarships, loan repayments,
    and bonuses are multiplied when combined with professional
    development programs for health professionals which the
    Committee believes to be essential components of recruitment
    and retention programs in the Indian health system. S. 1200
    establishes several professional development programs in Title
    I such as opportunities for advanced training and research,
    tribal cultural orientation, training in the administration and
    planning of tribal health programs and tribal demonstration
    projects for innovative recruitment, placement and retention
    programs, which may include professional development programs.
        Such additional training for health professionals is
    particularly important in developing leadership and
    collaboration skills and ensuring that a culturally-competent
    workforce exists within the Indian health system. The Committee
    strongly encourages the Secretary and tribal and urban Indian
    health providers to develop innovative programs or take
    advantage of existing models for such professional development
    to increase and maintain the number of Indian health
    professionals in the Indian health system.
        In addition, the Committee takes a long-term view of health
    professions in S. 1200. The most urgent placement needs are in
    the direct care positions, such as dentists, doctors, nurses,
    and pharmacists. In the long-term, Indian health professionals
    are also needed in educational positions to bolster recruitment
    levels and improve the new Indian health professionals' chances
    of success.
        The Committee has been informed that significant need
    exists at the tribal colleges and universities to increase the
    number of Indian instructors in the nursing programs.\59\ The
    Committee recognizes that Indian instructors often have
    personal knowledge of the health disparities in Indian
    communities and a deep commitment to serve these communities
    for the long-term. Indian educators increase the likelihood of
    success for Indian students and bring to the classroom the
    unique cultural competence required in the Indian health field.
    ---------------------------------------------------------------------------
        \59\Joseph F. McDonald, Ed.D., President, Salish-Kootenai College,
    Letter to Chairman John McCain, U.S. Senate Committee on Indian
    Affairs, September 22, 2005.
    ---------------------------------------------------------------------------
        With that in mind, the Committee included provisions in
    Title I of S. 1200 allowing a scholarship recipient to fulfill
    his or her service obligation (required in exchange for the
    scholarship) by teaching in a tribal college or university
    nursing or other health related program, provided the Secretary
    determines that health services to Indians will not be
    decreased. In addition, the Secretary may, prior to waiving any
    service obligation or repayment of a scholarship, consider
    placement of a scholarship recipient in a teaching capacity in
    a tribal college or university nursing or related health
    program. Other provisions for nursing grants were added to
    extend a preference in grant awards to tribal college and
    university nursing programs.
        Prior to including these provisions, the Committee
    considered the likelihood that inexperienced, new graduates
    might be placed in teaching positions. One tribal college
    president indicated that ``these [instructors] are clinically
    seasoned, mature [Bachelor of Science--Nursing] prepared nurses
    returning to school for educational and career mobility.''\60\
    Teaching positions available for these individuals would
    include lab coordinators and clinical instructors. This tribal
    college President also indicated that ``new [registered nurse]
    graduates of associate or generic baccalaureate programs would
    not be qualified to teach.''\61\
    ---------------------------------------------------------------------------
        \60\Joseph F. McDonald, Ed.D., President, Salish-Kootenai College,
    Letter to Honorable Don Young, U.S. House of Representatives, November
    1, 2005.
        \61\Joseph F. McDonald, Ed.D., President, Salish-Kootenai College,
    Letter to Honorable Don Young, U.S. House of Representatives, November
    1, 2005.
    ---------------------------------------------------------------------------
        The Committee believes these positions should be filled by
    experienced faculty and expects that the Secretary and the
    tribal colleges or universities would coordinate these
    opportunities and be selective in placing these individuals to
    avoid compromising the quality of education and accreditation.
        The Committee strongly encourages the Secretary to examine
    the Title I programs with targeted, holistic, long-term
    approaches in mind and to develop more opportunities to
    increase the number of Indians in the health professions. The
    Committee believes that in the long-run, improving health
    educational opportunities at every level will also contribute
    to improving the health of Indian communities.
        Home Health Care. Current law authorizes a feasibility
    study to be conducted on hospice care services. However, the
    IHS has never conducted that study and, now, 14 years later, to
    conduct such a study would greatly delay what have already been
    demonstrated to be much needed services.
        The Committee has been informed that some Indian tribes and
    tribal organizations, through pilot projects, have provided
    this type of service or other services such as home health care
    with great success. The Committee is concerned that not
    authorizing these and other long-term or home health care
    services through the Indian health care system--services that
    have been an accepted part of the national health care system
    and Medicare since 1983--will prevent IHS and tribes from
    utilizing a proven, effective health delivery vehicle.
        Currently, home health care, long-term care and hospice
    care are not readily available to most Native communities. Many
    Indians must travel long distances, only to be placed in
    facilities that are far from home, culturally unfamiliar, and
    not conducive to their overall well-being. Home health care is
    crucial for these individuals. Having culturally-appropriate
    facilities close to Indian communities not only promotes the
    patient's well-being, but enables family members to more easily
    visit the patient.
        Section 213 of S. 1200 authorizes services such as home
    health care, long-term care and hospice care, which are a
    standard part of the health care industry. If the Indian health
    system is to advance into the 21st Century, then Indian health
    programs must be authorized to make these services available
    for their Indian patients, if circumstances warrant.
        However, the Department of Justice has indicated that it
    has concerns regarding the provision of services for which no
    standards exist.\62\ To address those concerns, S. 4122 in the
    109th Congress included language that required standards to be
    in place from either the Secretary or the state in which the
    Indian health program was located. This type of requirement has
    been a part of the Indian health system as required in the
    Indian Self-Determination and Education Assistance Act.\63\
    ---------------------------------------------------------------------------
        \62\S. Hrg. 110-53 at 41 (March 8, 2007) (statement of C. Frederick
    Beckner III, Deputy Assistant Attorney General, Civil Division,
    Department of Justice).
        \63\See 25 U.S.C. 450f(a)(2). ``The contractor shall include in the
    proposal of the contractor the standards under which the tribal
    organization will operate the contracted program, service, function, or
    activity. . . .''
    ---------------------------------------------------------------------------
        Indian tribes want to ensure that the services authorized
    in Section 213 are consistent with those services reimbursable
    by Medicaid and, in particular, those services already
    authorized in compacts or contracts entered into by the tribes
    or tribal organizations and the IHS pursuant to the ISDEAA.
        To that end, S. 1200 authorizes the Secretary to promulgate
    standards to govern any service in the absence of state
    standards. It is the intent of the Committee that those
    services already authorized in compacts or contracts will
    remain so authorized and that the Secretary is authorized to
    issue interim standards in the absence of either state
    standards or final Secretarial standards. The Committee expects
    the Secretary to act promptly to promulgate these standards, so
    that services to Indian patients are not disrupted or denied.
        Convenient Care Services. Section 213 also authorizes the
    Secretary to provide funding to meet the health status
    objectives of the Act for convenient care services programs
    pursuant to section 306(c)(2)(A). Section 213 further
    authorizes health care delivery demonstration projects that
    include a ``convenient care services'' program as an
    alternative means of delivering health care services to
    Indians.
        In including this new provision, the Committee seeks to
    address the lack of access to health care services that exists
    in so many tribal communities, which may be due to limited
    hours of operation at existing health care facilities, lack of
    staff, or other factors. It is the Committee's hope that these
    convenient care services projects may expand the availability
    of health care, as well as decrease the need for more-costly
    emergency room visits, thereby reducing the over-stressed
    Contract Health Services budget.
        Traditional Health Care Practices. For much of America's
    history, the federal government's policy of assimilation and
    termination sought to destroy Indian cultures and religions, as
    well as tribal legal, political and economic institutions.
    Indian people were denied the exercise of traditional practices
    or punished, should those ceremonies be practiced, as well as
    were punished for speaking their own languages and observing
    other traditional ways.
        However, federal policy toward Native people has run the
    gamut, with the policy of one period often contradicting that
    of another. An example of such a policy shift occurred
    following the 1928 Merriam Report, which generated several
    initiatives to improve health conditions for Native
    Americans.\64\ One reform was the active solicitation of
    traditional Indian healers to participate in federal health
    services to Indians.
    ---------------------------------------------------------------------------
        \64\Merriam, Lewis (ed.), Institute for Government Research, The
    Problem of Indian Administration (1928) (commonly referred to as the
    ``Merriam Report'').
    ---------------------------------------------------------------------------
        The Indian Health Care Improvement Act currently contains
    provisions to promote long-practiced traditional health care
    practices of the Indian tribes served by IHS, tribal and urban
    Indian health programs, consistent with the standards for the
    provision of health care, health promotion, and disease
    prevention. Authority also exists for culturally appropriate
    health care with respect to specific programs (the Community
    Health Representative Program), specific elements of the Indian
    population (Indian youth and Indian women), and specific
    services and training (mental health). These practices
    encourage respect for and affirmation of concepts of Indian and
    Alaska Native cultural values, beliefs and traditions that
    Indian people define for themselves as a complement to western
    medical practices in promoting good health and curing illness.
        Former IHS Director Dr. Emery A. Johnson, in ``Policy and
    Procedures in reference to P.L. 95-341,'' the American Indian
    Religious Freedom Act of 1978, stated the Service's views as
    follows:

              The Indian Health Service has continued to recognize
            the value and efficacy to [sic] traditional beliefs,
            ceremonies, and practices of the healing of body, mind
            and spirit. . . . It is, therefore, the policy of the
            Indian Health Service to encourage a climate of respect
            and acceptance in which an individual's private
            traditional beliefs become a part of the healing and
            harmonizing force within his/her life.

        More recently, in 1994, IHS Director Michael H. Trujillo
    issued a ``Traditional Cultural Advocacy Program Policy
    Statement'' which states:

              The Indian Health Service (IHS) recognizes the value
            of traditional beliefs, ceremonies, and practices in
            the healing of body, mind, and spirit. The IHS
            encourages a climate of respect and acceptance in which
            traditional beliefs are honored as a healing and
            harmonizing force with individual lives, a vital
            support for purposeful living, and an integral
            component of the healing process. It is the policy of
            the IHS to facilitate [sic] right of American Indian
            and Alaska Native people to their beliefs and health
            practices as defined by the tribe's or village's
            traditional culture. This policy is meant to complement
            and support previously stated IHS policy for
            implementing the American Indian Religious Freedom Act
            of 1978 (Public Law 95-341, as amended).

        The Department of Veterans Affairs' National Center for
    Post- Traumatic Stress Disorder is adding traditional healing
    methods, such as talking circles and healing herbs, to modern
    medical treatments for American Indian and Alaska Native
    veterans and service personnel returning from active duty in
    the Middle East and suffering from post-traumatic stress
    disorder problems.\65\ The American Cancer Society (Society)
    includes Native American healing in a section on its website
    concerning treatment decisions.\66\ The Society, in connection
    with work at Montana State University, is providing funding to
    a group of Indian women health care workers on the Crow
    Reservation in Montana to help IHS providers understand
    traditional Crow healing practices and customs.
    ---------------------------------------------------------------------------
        \65\See Department of Veterans Affairs' National Center for
    Posttraumatic Stress Disorder website, www.ncptsd.va.gov/ncmain/
    index.jsp, and, e.g., www.adn.com/front/v-printer/story/9137819p-
    9054019c.html.
        \66\www.cancer.org/docroot/ETO/content/
    ETO_5_3X_Native_American_Healing.asp?sitearea=ETO.
    ---------------------------------------------------------------------------
        The Committee believes that health care treatment should be
    relevant to and effective for the population to be served, and
    thus regards traditional health care practices as an important
    part of culturally appropriate care for Indian people. These
    practices have been a part of the IHS, tribal and urban Indian
    health care system for years, are provided only at the request
    of the patient or family members, and are within the
    traditional culture of that individual. It is the Committee's
    understanding, based on Department of Justice testimony to the
    Committee on March 8, 2007, that no medical malpractice suit
    has ever been filed arising from a traditional health care
    practice.\67\ Thus, the risk for the United States in terms of
    liability appears to be insignificant, compared to the benefits
    of allowing Indian patients to obtain this care. DOJ's concerns
    are unfounded in light of the fact that traditional health care
    practices are based in Native healing sciences. The bill has
    the legislative purpose of providing for the highest possible
    health status for Indians without intruding on Indian self-
    determination.
    ---------------------------------------------------------------------------
        \67\S. Hrg. 110-53 at 14 (March 8, 2007) (statement of C. Frederick
    Beckner III, Deputy Assistant Attorney General, Civil Division,
    Department of Justice). See also S. Hrg. 110-53 at 104, testimony of
    Duke McCloud.
    ---------------------------------------------------------------------------
        Behavioral Health. S. 1200 has a strong focus on behavioral
    health. Title VII takes a comprehensive and integrative
    approach to behavioral health, providing both prevention and
    treatment programs for Indian children, youth, women and
    elders. The bill also emphasizes the interconnectedness of
    services related to alcohol and substance abuse, child welfare,
    suicide prevention and social services. Particular programs are
    authorized for Indian youth, Indian women, those affected by
    fetal alcohol disorder in Indian communities, and both the
    victims and perpetrators of child sexual abuse in Indian
    households.
        In addition to a comprehensive approach to addressing
    behavioral health services, the Committee recognizes and
    affirms the importance of providing care within the context of
    an individual's family, community and particular tribal
    culture, such as is used by the systems of care model.
        Indian Youth Suicide Prevention. The alarming suicide rates
    among Indian youth indicate a great need for improved,
    comprehensive behavioral health care services.
        The nation was shocked in March, 2005, when a troubled 16-
    year-old member of the Red Lake Band of Chippewa Indians in
    Minnesota shot and killed his grandfather, his grandfather's
    partner, five fellow high school students, a high school
    teacher and a security guard and seriously wounded several
    others at Red Lake High School on the reservation before
    killing himself. Several other young people from that
    reservation subsequently took their own lives.
        The publicity around the Red Lake incident, which was then
    the nation's second-most deadly school shooting, brought
    attention to the fact that, in Indian Country, suicide impacts
    a younger population than in the rest of the country. The
    suicide rate for Indian and Alaska Native youth, aged 15-24, is
    two and one-half times higher than the national average. Youth
    suicide ``clusters'' have also occurred on reservations in
    North and South Dakota, New Mexico and Arizona and in Native
    communities in Alaska.
        During the 109th Congress, the Committee held three
    hearings specifically on the issue of Indian youth suicide: one
    in Bismarck, North Dakota on May 2, 2005, and two oversight
    hearings in Washington, DC (on June 15, 2005, and on May 17,
    2006), to discuss the kinds of resources and services being
    provided to Indian youth who have expressed suicidal thoughts
    or attempted suicide.
        Based on the information developed through hearings, the
    Committee has included provisions in S. 1200 which address
    youth suicide as part of the behavioral health program
    provisions and in a culturally-appropriate manner. Section 708
    authorizes the Secretary to award grants for telemental health
    demonstration projects to provide counseling to Indian youth
    and health providers, training for Indian community leaders,
    and the development of culturally-relevant materials. The
    Committee recognizes that suicide prevention for Indian youth
    is a long-term effort that must address many multi-factorial
    causes. Questions such as whether the loss of cultural identity
    contributes to the youth suicide problem remain unanswered.
    Therefore, S. 1200 also makes suicide a priority for the IHS
    research agenda, particularly the identification of various
    factors that either protect the tribal community or make that
    community at risk for suicides, and the role the loss of tribal
    identity plays in suicidal behavior. Finally, provisions
    included in Title I encourage more Indian people to enter into
    the psychology profession by increasing the number of grants
    for the program commonly referred to as In-Psych (Indians into
    the Psychology) from three to nine and by authorizing a
    specific level of funding.
        Urban Indians. Providing health care services to urban
    Indians has been a part of Federal policy for nearly 40 years.
    Congress began funding urban Indian clinics in 1967 when
    $321,000 was provided for an Indian clinic in Rapid City, South
    Dakota.\68\
    ---------------------------------------------------------------------------
        \68\Senate Report No. 94-133, at 136. In 1972, Congress added
    funding to the IHS appropriations for a pilot program in Minneapolis.
    Others followed in 1973 in Oklahoma City, Seattle and California (which
    covered nine urban Indian organizations).
    ---------------------------------------------------------------------------
        Congress specifically included urban Indian health programs
    as part of the Indian health care system in the Act in 1976,
    recognizing that the Federal obligation for health care
    extended to these individuals. These provisions sought to
    correct disparities in health levels for Indians living in
    urban areas, first as pilot programs and later permanently in
    the Indian health care system.\69\
    ---------------------------------------------------------------------------
        \69\See Senate Report Nos. 94-133, 100-508 and 108-411.
    ---------------------------------------------------------------------------
        The policies and status of Indians and Indian tribes under
    Federal laws, treaties and judicial decisions provide ample
    support for continuing and improving programs for urban
    Indians. Under this varied history, the Federal Government had
    dealt with Indian tribes in a variety of ways: some by treaty,
    others not by treaty. The Federal Government had ignored some
    Indian tribes completely. Other Indian tribes were
    legislatively excluded from receiving services under some
    administrative programs, yet were allowed to exercise treaty
    rights. Some Indian tribes were ``terminated,'' yet later
    ``restored'' to a government-to-government relationship with
    the United States.
        Courts have long held that Congress has the broad power to
    legislate for the benefit of Indians, even if located off of
    the reservation, and to define who is an Indian and for what
    purposes they may be provided services, even if they may not be
    an enrolled member of a federally-recognized Indian tribe.\70\
    ---------------------------------------------------------------------------
        \70\U.S. Const., Art. I, Sec. 8, cl. 3. See also Cohen, Felix.
    Handbook of Federal Indian Law, at 23. 1982 ed.; U.S. v. Holliday, 70
    U.S. 407, 417 (1865) (the broad power also includes Congress' dealings
    with individual Indians). As the courts suggest, Federal policy for
    Indians cannot be confined to reservation boundaries. (``The overriding
    duty of our Federal Government to deal fairly with Indians wherever
    located has been recognized by this Court on many occasions.'' Morton
    v. Ruiz, 415 U.S. 199 (1974) (citing Seminole Nation v. U.S., 316 U.S.
    286, 296 (1942); (``Patterns of cross or circular migration on and off
    the reservations make it misleading to suggest that reservations and
    urban Indians are two well-defined groups.'' U.S. v. Raszkiewicz, 169
    F.3d 459, 465 (7th Cir. 1999).)
    ---------------------------------------------------------------------------
        For example, Congress has enacted laws which define Indians
    in different ways for different purposes.\71\ Even the criminal
    statutes under Title 18 of the U.S. Code regarding crimes on
    Indian reservations do not define who is an Indian. In other
    cases, Congress did not define Indians, or place geographical
    limitations on the service areas in which they may be served.
    The Snyder Act, 25 U.S.C. 13, authorizes permanent funding for
    health care for ``the Indians throughout the United States.''
    This statute does not confine the services to Indians who are
    members of current federally-recognized tribes or to those
    living only on reservations. The Snyder Act has never been
    repealed nor otherwise limited in this respect. Under this Act,
    Congress has provided a more inclusive definition of urban
    Indian than mere membership in a federally-recognized Indian
    tribe, including members of ``terminated'' tribes, that is,
    groups that once had a political government relationship with
    the United States which was ended under the ``termination''
    policy of Federal-Indian relations.
    ---------------------------------------------------------------------------
        \71\See, e.g., Indian Arts and Crafts Act, Pub.L. 101-644, 25
    U.S.C. 305; No Child Left Behind Act, Pub. L. 107-110, 25 U.S.C. 7491;
    and the American Indian Probate Reform Act of 2004, Pub. L. 108-374, 25
    U.S.C. 2201.
    ---------------------------------------------------------------------------
        Termination was another failed Federal Indian policy
    designed to end the government-to-government relationship with
    Indian tribes and assimilate their members into the larger
    society. When that policy gave way to self-determination,
    however, and Congress sought to try to remedy the devastating
    effects of termination, Congress saw fit to continue the health
    services in the Act to those individuals. See Menominee Tribe
    v. U.S., 391 U.S. 404 (1968). Likewise, by including members of
    state-recognized tribes, Congress recognized that several
    Indian tribes had treaty relations with individual states
    before the Federal Government was established.
        Congress did not in this Act recognize either the
    ``terminated tribes'' or the state-recognized tribes on the
    same basis or for the same purposes as the federally-recognized
    tribes under this Act. However, the U.S. Supreme Court has
    found that extending Federal protection for limited purposes,
    such as for services provided in this Act, is within Congress'
    power.
        Further, in adopting S. 1200, the Committee is of the
    opinion that the Congress was on firm constitutional footing
    based on long-standing precedent. Indeed, the U.S. Supreme
    Court has held that ``it is not meant . . . that Congress may
    bring a community or body of people within the range of this
    power by arbitrarily calling them an Indian tribe, but only
    that in respect of distinctly Indian communities the questions,
    whether, to what extent and for what time they shall be
    recognized and dealt with as dependent tribes requiring the
    guardianship and protection of the United States are to be
    determined by Congress, and not by the courts.'' U.S. v.
    Sandoval, 231 U.S. 28, 46 (1913) (emphasis added). Accordingly,
    the Act extends health benefits to members of these groups
    (terminated tribes and state-recognized tribes) without
    extending Federal recognition to them for all purposes.
        In enacting this Act, the Committee has found ample
    justification for extending health services to the Indians who
    ended up in these urban areas because of several major
    developments:

              First, Indians were provided an opportunity to work
            and share in the Nation's prosperity in industries
            prior to and during World War II; second, thousands of
            Indian men and women served in the Armed Forces away
            from their reservation, traditional communities or
            Alaska Native villages; third, formal government
            relocation programs moved many Indian families from low
            employment, rural areas to urban areas where
            ``employment opportunities'' were considered more
            readily available; and fourth, countless numbers of
            Indians attempting to escape depressed conditions on
            their reservations voluntarily relocated.\72\
    ---------------------------------------------------------------------------
        \72\Senate Report 94-133, at 131.

        The comprehensive approach of this Act is needed to more
    fully implement the Federal responsibility for Indian health
    care, and, even more so today, to address health disparities
    facing the Indians who had moved from the reservations as a
    result of the relocation policies. Relocating Indians from
    reservations to urban areas was the Federal policy and program
    first begun in 1931.\73\ ``Relocation complemented other
    termination programs designed to promote rapid assimilation.
    Once relocated, Indians were cut off from the special federal
    services that had been available to them as reservation
    residents.''\74\
    ---------------------------------------------------------------------------
        \73\Felix Cohen, Handbook of Federal Indian Law (1982 ed.), at 169.
        \74\Id.
    ---------------------------------------------------------------------------
        Congress has previously recognized that the establishment
    of urban Indian health programs was necessary to rectify the
    errors of failed Federal Indian policies such as
    relocation.\75\ The Committee further found that Title V of the
    original Act ``represent[ed] a Federal policy commitment to
    provide the essential authorities and financial resources to
    permit urban Indian organizations to develop needed health
    services and to strengthen relationships with existing
    community health and medical care programs.''\76\
    ---------------------------------------------------------------------------
        \75\Senate Report No. 94-133, at 138.
        \76\Id., at 140.
    ---------------------------------------------------------------------------
        The justifications for this policy are still valid today.
    Recent statistics indicate that urban Indians suffer health
    disparities, as do Indians living on reservations. For example,
    the mortality rates are higher due to accidents (38% higher
    than other populations), chronic liver disease and cirrhosis
    (126% higher), diabetes (54% higher), alcoholism (178% higher),
    and sudden infant death syndrome (157% higher).\77\
    ---------------------------------------------------------------------------
        \77\The Health Status of Urban American Indians and Alaska Natives,
    Urban Indian Health Institute, March 16, 2004, at v. Available at
    www.uihi.org. See also American Journal of Public Health, August 2006,
    Vol. 96, No. 8, ``A Nationwide Population-Based Study Identifying
    Health Disparities Between American Indians/Alaska Natives and the
    General Populations Living in Select Urban Counties.''
    ---------------------------------------------------------------------------
        The Committee believes that continuation of services to
    urban Indians, recognized in the original Act and affirmed by
    S. 1200, makes sense from both policy and fiscal perspectives.
    The Committee has received testimony that these urban Indian
    health programs improve health services for Indians located in
    the urban centers in a highly cost-effective manner.
        In addition, the Committee has received testimony that
    without the urban Indian health programs, urban Indians would
    not seek care or could delay seeking proper medical attention
    until their health problems erupt into emergency situations or
    reach advanced stages when treatment is costlier and the rate
    of survival is much lower.
        By being located closer to the urban Indians than the
    tribal health programs on the reservations, urban Indian health
    programs reduce the number of emergency room visits by
    providing early disease prevention services.
        For example, the South Dakota Urban Indian Health Center
    operates three clinics with more than 17,500 patient encounters
    per year under the Title V program. This center provides such
    services as a foot care home visit program whereby Community
    Health Representatives conduct home visits to assess diabetic
    patients (or those at risk for diabetes). These home visits are
    a critical part of chronic disease management, particularly in
    avoiding amputations due to diabetes.
        The First Nations Community Health Source in Albuquerque,
    New Mexico provides dental, primary, and behavioral health care
    for approximately 45,000 urban Indians and handles
    approximately 12,700 patient encounters per year under the
    Title V program.
        The Native Americans for Community Action in Flagstaff,
    Arizona provides immunizations, mental health and youth
    substance abuse prevention services among several other primary
    care services for urban Indians. The Committee has received
    testimony suggesting that the patients at this urban Indian
    health center would either have to travel 100 or more miles to
    visit an IHS clinic on the reservation or wait two or three
    weeks for an appointment at the local Community Health Center.
    Either alternative would impose significantly more burdens on
    the patient, and the testimony further suggests that most
    patients would simply avoid the care altogether.
        The Tucson Indian Center in Tucson, Arizona also provides
    important disease prevention services such as substance abuse
    prevention, wellness programs and immunizations. This Center
    provides services for over 2,500 patient encounters under the
    Title V programs.
        The health program operated by the Nevada Urban Indians,
    Inc. in Reno, Nevada provides, among other things, immunization
    and diabetes education programs and experienced over 9,000
    patient encounters in 2005. The Native American Rehabilitation
    Association of the Northwest, Inc. in Portland, Oregon
    experiences nearly 9,300 patient encounters per year, including
    1,040 for mental health care and 3,400 for alcohol and drug
    treatment. The N.A.T.I.V.E. Project in Spokane, Washington
    provides a community wellness program and community outreach
    services for diabetes screening and health education for a
    community of approximately 12,000 urban Indians.
        These programs, particularly the wellness, diabetes, and
    behavioral health programs are critical to preventing the
    development of diseases which may require long-term disease
    management such as for diabetes and alcohol or drug addictions.
    In addition, the outreach, screening and home-based care
    programs are vital in ensuring the patients receive early
    intervention and care rather than waiting until they need
    emergency services which cost far more than intervention
    services.
        Urban Indian health programs provide culturally-appropriate
    health care for Indians. The Committee has received testimony
    that Indians may avoid non-Indian (or ``mainstream'') health
    providers who are unfamiliar with or insensitive to Indian
    culture. The urban Indians have confidence in the urban Indian
    health programs and are more likely to seek care when the
    provider recognizes and respects culturally-appropriate care.
        Urban Indian health programs also address continuity of
    care for Indians migrating between the urban areas and
    reservations. Even though the disavowed policy of relocation no
    longer forces such migration, moving from the reservation to
    urban areas is not uncommon for these individuals, and neither
    is their return to the reservation. For example, the urban
    Indians may travel to the reservation for traditional
    ceremonies, tribal political (elections) or cultural events
    (such as pow-wows), clan or family events, and so on. On the
    other hand, Indians may move to the urban areas for job or
    educational opportunities--and carry with them the need for
    continuity of care. The Committee has received testimony that
    these programs recognize the migration and account for it in
    their patient care, particularly for quality follow-up care.
        The urban Indian health programs provide services for the
    uninsured Indians who might not be able to obtain care
    elsewhere. With poverty rates of urban Indians hovering at 25%
    (compared to 14% for the general population), and nearly half
    living below 200% of the Federal poverty level (compared to 30%
    for the general population),\78\ it is no surprise that many
    urban Indians are uninsured. The Committee has received
    testimony that in Boston, MA, 87% of the Boston Indian Center's
    clients have no health insurance. In Arizona, nearly two out of
    three urban Indians have no insurance.
    ---------------------------------------------------------------------------
        \78\The Health Status of Urban American Indians and Alaska Natives,
    Urban Indian Health Institute, at v.
    ---------------------------------------------------------------------------
        The Committee believes that the urban Indian health
    programs are a crucial component in the overall Federal effort
    to reduce the health disparities for the urban Indians. Without
    such services by the Title V health programs, it is quite
    likely that the health disparities among the urban Indians will
    increase. This result would contradict the Congressional policy
    set forth in this Act and in other statutes of increasing
    access to health care and of remedying health disparities that
    result from the past failed Federal Indian policies.
        Dental Health Aide Therapists. Decades of inadequate access
    to dental care, along with other factors that contribute to the
    generally worse health condition of Indians as compared to the
    general population, have led to a true epidemic of dental
    disease in Indian communities, and in Alaska Native
    communities, in particular.
        During the 108th and 109th Congresses, there was
    considerable discussion surrounding the Dental Health Aide
    Therapists (DHAT) Program in Alaska Native communities. The
    Committee received testimony regarding the crisis in oral
    health care in Alaska Native communities and how the DHAT
    program was a result of Alaska Native leaders and health
    providers searching for a means of addressing it. The Committee
    believes that the use of Alaska Natives trained through the
    DHAT program to serve as dental health aide therapists in
    Alaska is a necessary response to this access to care crisis.
        The DHAT program in Alaska has been part of the Community
    Health Aide Program since 2002, and DHATs provide a wide range
    of oral health care promotion and disease prevention services.
    For the most part, the DHAT program is supported and applauded
    for its efforts in reducing the extraordinary dental crisis in
    Alaska Native communities. However, some activities have
    generated controversy because they require the performance of
    certain irreversible procedures, specifically, the treatment of
    dental caries, pulpotomies and extractions of teeth.
        In January, 2006, the American Dental Association (ADA),
    the Alaska Dental Society (ADS) and several individual dentists
    filed a lawsuit in Alaska Superior Court, seeking to stop the
    practice of dentistry and dental surgery by non-dentists by
    asking the court to declare the Alaska Native Tribal Health
    Consortium and its Dental Health Aide Therapists program in
    violation of state dental licensing laws. On June 27, 2007, the
    Alaska Superior Court dismissed the case, noting in its
    decision that DHAT is part of the Community Health Aide
    Practitioner Program and Congress clearly intended the
    utilization of paraprofessionals in providing care through both
    CHAP and DHAT.
        When the House Resources Committee marked up its version of
    the Indian health reauthorization in the second session of the
    109th Congress, the Committee agreed to an amendment offered by
    Representative Young (R-AK) regarding the Dental Health Aide
    Therapist program in Alaska. The language, which the Committee
    has been informed was agreed to by the American Dental
    Association and the Alaska Native Health Board, prohibits
    dental health aide therapists from performing all oral and jaw
    surgeries except pulpal therapy or extraction of adult teeth
    after consultation with a licensed dentist in a dental
    emergency. That agreed-upon bill language is carried forward
    and included in S. 1200.
        National Bipartisan Commission on Indian Health Care. The
    Committee intends that S. 1200 will provide many much-needed
    improvements to the Indian health system. However, adequate
    funding levels remain a significant factor in achieving those
    improvements.
        For several years, the Committee has received testimony
    regarding the substantial funding needs for Indian health.\79\
    Federal appropriations have increased over time, but, as
    evident in the IHS Level of Need Funded Study, have not reached
    optimal levels.\80\ While the reimbursements from Medicaid and
    Medicare have been beneficial in adding additional resources,
    they are not a complete solution to the funding deficiencies.
    ---------------------------------------------------------------------------
        \79\See Hearing on the President's Fiscal Year 2008 Budget Request
    for Indian Programs Before the Senate Comm. on Indian Affairs, 110th
    Cong., 1st Sess., February 15, 2007, S. Hrg. 110-48; Hearings on the
    President's Fiscal Year 2007 Budget Request for Indian Programs Before
    the Senate Comm. on Indian Affairs, 109th Cong., 2nd Sess., February
    14, 2006, S. Hrg. 109-396, Pt. 1 and February 23, 2006, S. Hrg. 109-
    396, Pt. 2; Hearing on the President's Fiscal Year 2006 Budget Request
    for Indian Programs Before the Senate Comm. on Indian Affairs, 109th
    Cong., 1st Sess., February 16, 2005, S. Hrg. 109-9; Hearings on the
    President's Fiscal Year 2005 Budget Request for Indian Programs Before
    the Senate Comm. on Indian Affairs, 108th Cong., 2nd Sess., February 11
    and 25, 2004, S. Hrg. 108-420; Hearing on the President's Fiscal Year
    2004 Budget Request for Indian Programs Before the Senate Comm. on
    Indian Affairs, 108th Cong., 1st Sess., February 26, 2003, S. Hrg. 108-
    60; Hearings on the President's Fiscal Year 2003 Budget Request for
    Indian Programs Before the Senate Comm. on Indian Affairs, 107th Cong.,
    2nd Sess., March 5, 7, and 14, 2002, S. Hrg. 107-360.
        \80\See, e.g., ``LNF Primer,'' U.S. Department of Health and Human
    Services, Indian Health Service, located at http://www.ihs.gov/
    NonMedicalPrograms/Lnf/docs2003/Primer.pdf.
    ---------------------------------------------------------------------------
        The Committee has concluded that an overarching assessment
    of need and financing mechanisms is warranted to address the
    health disparities and financing for Indian health care.
    Accordingly, section 814 establishes the National Bipartisan
    Commission on Indian Health Care to study the optimal manner in
    which to provide and finance health care services to Indians.
        This Commission will have broad authority to conduct
    hearings and other activities needed to provide Congress with
    comprehensive and thoughtful recommendations regarding the
    optimal means of delivering health care services to Indians.
    The Committee intends that this Commission will also serve as
    an appropriate forum for addressing outstanding questions
    relative to financing, including, among others, balancing
    concerns about overutilization and deficiencies.
        Indian Health Care Facilities Construction. During the
    109th Congress, much discussion between the National Steering
    Committee and the Committee centered around section 301, which
    directs the Secretary to maintain a health care facility
    priority system for construction.
        Background: Development of the Priority System. In the
    early 1980's, the IHS developed a health care facilities
    priority system (Priority System) for construction of various
    types of health care facilities in Indian communities. In 1988,
    pursuant to Public Law 100-713 (as amended by Public Law 102-
    573), Congress required the IHS to provide an annual report
    which set forth (1) the current priority system; (2) the
    planning, design, construction and renovation needs of the top-
    10 priority inpatient and outpatient facilities (including
    staff quarters); (3) the justification and projected costs of
    these projects; and (4) the methodology for establishing the
    priorities.
        In this Priority System, construction projects for
    hospitals, health centers, staff quarters and youth regional
    treatment centers go through three key phases, wherein the IHS
    solicits proposals for health facility construction and ranks
    the proposals according to their relative need for
    construction.\81\
    ---------------------------------------------------------------------------
        \81\For a detailed discussion on the Priority System and the three
    phases, see U.S. Department of Health and Human Services, Indian Health
    Service, ``Healthcare Facilities Construction Priority System
    Methodology,'' June 3, 2004, located at http://www.ihs.gov/
    TribalLeaders/triballetters/2004_Letters/06-28-2004_Enclosure.pdf; and
    ``Health Care and Related Facilities,'' located at http://www.ihs.gov/
    NonMedicalPrograms/DFEE/InfoSheets/infosheet.PDF.
    ---------------------------------------------------------------------------
        The projects are selected for inclusion on a ``Priority
    List'' after completion of Phases I and II, then move up the
    Priority List as Phase III is completed and appropriations for
    the projects are provided.
        Congressional Directive To Revise the Priority List. In
    1999, in the conference report accompanying the FY 2000
    Interior Appropriations Act (House Report 106-406), Congress
    directed the IHS, working closely with Indian tribes, to review
    and revise the Priority System. In recognizing the ``extreme
    need for new and replacement hospitals and clinics,'' Congress
    noted that ``there should be a base funding amount, which
    serves as a minimum annual amount in the budget request.''
    Congress further noted that several issues needed to be
    considered in revising the Priority System and that ``a more
    flexible and responsive program can be developed that will more
    readily accommodate the wide variances in tribal needs and
    capabilities.''\82\
    ---------------------------------------------------------------------------
        \82\House Report 106-406, at 138-139.
    ---------------------------------------------------------------------------
        In response to this directive, the IHS Director convened a
    Facilities Appropriations Advisory Board (FAAB) and a
    Facilities Needs Assessment Workgroup to review the Priority
    System and make recommendations for revision. According to the
    IHS, the FAAB was comprised of 12 members representing Indian
    tribes and two members representing the IHS, and the Workgroup
    was established by the IHS Director to make recommendations to
    the FAAB. The Committee has been informed that, earlier this
    year, the FAAB submitted final recommendations to the IHS
    Director, but no final decision has been made on these
    recommendations.
        Meanwhile, in 1999, the National Steering Committee
    developed language regarding the Priority System contained in
    section 301 of the various iterations of bills introduced for
    the reauthorization of the Act. The language in section 301
    remained primarily the same until 2006, when the Committee
    refined certain provisions and included an additional protected
    category in section 301(c)(1)(D), referred to as the
    ``grandfather'' provision, in S. 4122, introduced at the end of
    the 109th Congress.
        Grandfather Provision. The ``grandfather'' provision of
    section 301(c)(1)(D) protects the priority status of health
    care facilities (in certain categories) on the Priority List
    from being affected by changes to the Priority System being
    contemplated by the IHS, pursuant to the 1999 Interior
    Appropriations Conference Report instruction. These projects
    have been on the Priority List since at least 1991.
        Under the ``grandfather'' provision, the protected
    categories include:
        (1) Top 10 Projects. Projects in the FY 2008 IHS budget
    justification for the 10 top-priority inpatient, outpatient,
    staff quarters and Youth Regional Treatment Centers (YRTC)
    projects. Currently, those projects include:
        Inpatient: Phoenix and Whiteriver, AZ; Barrow and Nome, AK.
        Outpatient: Ft. Yuma, Red Mesa, Kayenta, San Carlos and
    Winslow-Dilkon, AZ; St. Paul, AK; Sisseton, Eagle Butte and
    Rapid City, SD.
        YRTC: Wadsworth, NV; Central-Southern and Northern
    California.
        (2) Phase I and II. Projects that have completed Phases I
    and II of the Priority System in effect on the date of
    enactment of the Indian Health Care Improvement Act Amendments.
    Currently, these projects include: Ft. Belknap, MT; Wagner, SD;
    Sells and Bodaway-Coppermine, AZ; Gallup, Alamo, Albuquerque,
    Pueblo Pintado, Crownpoint and Shiprock, NM.
        During the 109th Congress, a third category was added:
        (3) Secretarial Discretion. Projects not in the other two
    protected categories and selected on the initiative of the
    Secretary or at the request of an Indian tribe or tribal
    organization.
        During the 109th Congress, the IHS, FAAB and Workgroup
    began finalizing their recommendations and draft revisions to
    the Priority System. The Committee had been informed that these
    drafts purported to revise what would constitute Phases I and
    II of the Priority System. These proposed changes could then
    have affected what projects would be ``grandfathered'' under
    section 301(c)(1)(D) and thus change the priority of several
    projects which have been waiting on the Priority List for many
    years.
        Due to the uncertainty of when the IHS will approve the
    final changes (before or after the Act is reauthorized) and
    what those changes will consist of, the third category was
    added to ensure that the Secretary still has authority to
    prioritize projects which might no longer qualify under the
    other two protected categories.
        Innovative Approaches. Currently, construction funding
    generally has been applied to the projects on the Priority
    List. The Committee has been informed that the total cost of
    the current Priority List is in excess of $200 million as of FY
    2008, with other unmet needs in the billions of dollars. At the
    time of the congressional directive in 1999, the construction
    appropriations was over $41 million and even reached over $94
    million in FY 2004. The amount of appropriations increased
    slightly until FY 2006, after which it has decreased quite
    significantly.
        Ideally, with a continuation of the level of funding
    appropriated following the conference report directive in FY
    2000, the current Priority List should have been nearing
    completion by the time revisions to the Priority System were
    finalized. Unfortunately, significant unforeseen national
    events occurred since the Appropriations Committee's directive,
    which affected the amount of available appropriations for
    closing out the current Priority List and allowing other
    projects to be added to the List and built. Thus, the current
    Priority List has not been completed, whereas the revisions to
    the Prriority System are nearing completion.
        The Committee has been informed that while projects have
    been on the Priority List for a number of years, many other
    needed projects have never been on the Priority List. The
    Committee had been requested to include an alternative approach
    in S. 1200 to address the remaining unmet needs through the
    concept of an Area Distribution Fund. Under an Area
    Distribution Fund, a portion of construction funding could be
    devoted to IHS Area priorities. This localized approach would
    allow other smaller projects to be completed, instead of
    waiting until the entire current Priority List is completed.
        In light of the facilities backlog, section 301(f) of S.
    1200 encourages the Secretary to seek innovative approaches to
    address unmet needs for health care facility construction, and
    requires the Secretary to consult and cooperate with Indian
    tribes in developing these innovative approaches. The Committee
    recognizes that the Secretary has engaged in considerable work
    revising the Priority System thus far. These proposed revisions
    may also be useful in developing innovative approaches.
        However, the Committee encourages the Secretary, prior to
    finalizing the revisions, to take into consideration the fiscal
    circumstances under which the 1999 congressional directive
    occurred, relative to those experienced today, and how
    innovative approaches to financing construction may be
    implemented in such a manner which is fair and equitable to
    those Indian tribes to be served by the projects on the current
    Priority List and those Indian tribes which have not had the
    opportunity to have their projects placed on the list.
        The Committee expects the IHS to work with Indian tribes in
    developing the types of innovative approaches to pursue, as
    well the contours of those approaches. The Secretary has used
    broad authority to develop and maintain the Priority System
    since the 1980s, and section 301(f) also provides broad
    authority to implement innovative approaches, such as an Area
    Distribution Fund, if, after consultation with the Indian
    tribes, it is determined that this is an appropriate system to
    address the health facility needs of Indian communities. The
    Committee also expects the IHS to work with Indian tribes and
    to submit a minimum budget request consistent with the
    congressional directive which will accommodate both the current
    Priority List and any innovative approaches.
        Elevation of the IHS Director. Section 601 of S. 1200
    elevates the Director of the IHS to the position of Assistant
    Secretary for Indian Health within the Department of Health and
    Human Services. The purpose of this elevation is to foster the
    government-to-government relationship between Indian tribes and
    the United States, facilitate advocacy for Indian health
    policy, and promote consultation on Indian health matters.
    Presently, the Director of the Indian Health Service is
    appointed by the President and confirmed by the Senate pursuant
    to 25 U.S.C. 1661(a). The Director reports to the DHHS
    Secretary through the Assistant Secretary for Health.
        During the 109th Congress, the provisions elevating the
    Director to the Assistant Secretary were included in the
    introduced bill, S. 1057, but not in the final iteration, S.
    4122, due to objections by the Administration. The Committee
    has continued to receive testimony in strong support of
    elevation from the Indian tribes.\83\ The testimony received by
    the Committee and consultation with Indian tribes during the
    110th Congress have counseled in favor of including the
    provisions in S. 1200 as part of the IHCIA reauthorization.
    ---------------------------------------------------------------------------
        \83\Indian Health Care Improvement Act: Hearing of the Senate
    Indian Affairs Committee, 110th Cong., 1st Session, S. Hrg. 110-53 at
    74 (March 8, 2007) (statement of Rachel Joseph).
    ---------------------------------------------------------------------------
        Previous bills establishing this position in the Department
    have either been favorably approved by the Committee or passed
    the Senate: S. 558 (108th Congress, passed by the Senate), S.
    214 (107th Congress, ordered reported by the Committee), S. 299
    (106th Congress, passed by the Senate), S. 1770 (105th
    Congress, passed by the Senate), S. 311 (104th Congress,
    ordered reported by the Committee), and S. 2067 (103rd
    Congress, passed by the Senate).
        Like these legislative predecessors, S. 1200 facilitates
    the government-to-government relationship between the United
    States and Indian tribes by providing the necessary leadership
    within the Administration on Indian health issues to bring
    focus, priority and national attention to the health care
    status and needs of Indians. Section 601 is intended to enhance
    the Federal capacity to respond to the ongoing health crisis in
    Indian Country and the continuing frustration of Indian tribes
    and patients that their needs and concerns are not adequately
    addressed under the current administrative policy and budgetary
    processes.
        Previous Senate reports further elaborate upon the
    evolution of the IHS and the need and purposes for establishing
    this position. (See Senate Report Nos. 108-76, 107-170, 106-
    148, 105-319, and 103-327.) Nevertheless, an abbreviated
    discourse is necessary to inform the continuing need for
    elevating the Director to the Assistant Secretary for Indian
    Health.
        Budgetary Improvement. The IHS operates a comprehensive
    health care delivery system nationwide through a variety of
    health care facilities and services and through contracts and
    compacts with Indian tribes under the Indian Self-Determination
    and Education Assistance Act, with Urban Indian Organizations,
    or with private health care providers through the contract
    health services program.
        Efforts to address Indian health care needs have been
    tempered by the steady decline in purchasing power of the IHS
    budget. Indeed, the IHS 2004 study on Level of Need Funding
    indicated that the funding fell short of meeting the health
    care needs of Indian people and was operating at approximately
    a 40% deficiency.
        The Committee has not seen appreciable decreases to this
    deficiency to convince it that elevation is not necessary. One
    of the principal justifications for the elevation has been past
    Administrations' failure to incorporate tribal recommendations
    in the final budget request, despite tribal participation
    throughout the budget process.
        For example, the Committee received testimony estimating
    health care needs in excess of $19.7 billion to achieve parity
    for Indian people.\84\ Past budgets have reflected marginal
    increases, even in the era of tight budgets, but these
    increases have not closed the gap on the ``level of need''
    funding deficiency.
    ---------------------------------------------------------------------------
        \84\S. Hrg. 110-48 at 184 (testimony of H. Sally Smith).
    ---------------------------------------------------------------------------
        In addition, the Committee has also received testimony that
    Indian tribes requested continued funding for the Urban Indian
    Organizations during the annual budget formulation
    sessions.\85\ However, the FY 2007 and FY 2008 President's
    Budget Requests zeroed out funding for the Urban Indian
    Organizations.\86\ These decreases are disturbing in light of
    the alarming disparities that exist between the health status
    of the Indian population and other populations in the United
    States. These disparities have been well-documented in past
    Committee reports, legislation and testimony before the
    Committee.\87\
    ---------------------------------------------------------------------------
        \85\Id.
        \86\U.S. Department of Health and Human Services, Indian Health
    Service, Fiscal Year 2007, Justification of Estimates for
    Appropriations Committees, at IHS-49, and U.S. Department of Health and
    Human Services, Indian Health Service, Fiscal Year 2008, Justification
    of Estimates for Appropriations Committees, at CJ-121.
        \87\See, for example, footnotes 46 and 76, above.
    ---------------------------------------------------------------------------
        Although the Committee has received testimony that the
    Director has access and policy input within the DHHS, the
    health care status of Indians remains at such levels which
    necessitate a modified level of leadership and advocacy. The
    establishment of the Assistant Secretary for Indian Health will
    facilitate advocacy within DHHS and the Office of Management
    and Budget for the funding resources and policies that are
    necessary to effectively and efficiently address the health
    care needs and concerns of the Indian people.
        Regulatory and Administrative Improvement. The Indian
    health care system presents cross-cutting issues which involve
    DHHS agencies other than the IHS. The Committee recognizes the
    current attention given to Indian health issues as well as the
    revitalization of the Intra-departmental Council on Native
    American Affairs within the DHHS which would address matters in
    DHHS agencies affecting Indian health.
        Despite this revitalization, concerns have been raised with
    the Committee that broad administrative and regulatory matters
    within DHHS affecting Indian health have not been addressed
    either properly or timely. The Committee intends that this
    position would create an opportunity for the Assistant
    Secretary for Indian Health to be involved in the formulation
    of policy and regulatory authority on these larger issues which
    affect Indian health rather than simply addressing matters
    which are solely Indian in nature.
        As stated in previous Committee reports, the Committee
    continues to believe that the institutionalization of a senior
    policy official responsible for Indian health within the DHHS
    is necessary to bring parity and reduce deficiencies in the
    delivery of Indian health care services. This
    institutionalization is also important to ensure that the
    advocacy and the knowledge of the United States legal and moral
    obligations for Indian health and the mission of the IHS is
    carried forward in future Administrations.
        Third Party Reimbursements. Funding from sources other than
    IHS appropriations has been identified as a factor affecting
    the availability of health care services for Indians.\88\ Those
    funding sources include third-party reimbursements from
    Medicaid and Medicare. In some cases, these reimbursements
    constitute up to 50% of the medical care budget for a
    particular Indian health program.\89\
    ---------------------------------------------------------------------------
        \88\GAO Report No. GAO-05-789, at 4.
        \89\Id., at 5.
    ---------------------------------------------------------------------------
        With more resources, the Indian health care system could
    provide more services, and the Committee strongly encourages
    IHS and the Indian tribes to seek additional resources to
    supplement the appropriated sums provided annually.\90\ The GAO
    noted that ``[f]acilities with higher reimbursements had
    additional funds with which they could hire staff, purchase
    equipment and supplies, and renovate their buildings.''\91\ In
    one case, 31 percent of a facility's clinical providers and
    other staff was funded by third party reimbursements.\92\
    ---------------------------------------------------------------------------
        \90\S. 1200 includes amendments to the ISDEAA which authorize the
    Native American Health and Wellness Foundation to promote the mission
    of IHS through such means as receiving donations which supplement, not
    offset, appropriations. Offsetting in Indian health care programs is
    generally prohibited by law. See 25 U.S.C. Sec. 1641(a).
        \91\GAO Report No. GAO-05-789, at 26.
        \92\Id.
    ---------------------------------------------------------------------------
        S. 1200 provides for an increase in access to Medicaid by
    removing barriers through waivers of premiums and cost-sharing
    at Indian health facilities and by codifying agency regulations
    or practices which recognize the unique nature of and special
    circumstances applying to Indian property, particularly trust
    and restricted property.\93\ Likewise, S. 1200 provides other
    means of removing barriers to obtaining third-party
    reimbursements, such as the process for seeking waivers of
    sanctions, which promotes favorable state-tribal relations.
    ---------------------------------------------------------------------------
        \93\As a general rule, these special types of property are not
    included in eligibility calculations for income taxes or federal
    benefits.
    ---------------------------------------------------------------------------
        Waiver of Medicaid Co-Pays. One fundamental purpose of the
    Indian Health Care Improvement Act is to improve access to
    health care for Indian people. Removing barriers to such access
    is a critical aspect in accomplishing that purpose. To that
    end, section 204 of Title II of S. 1200 prohibits cost-sharing
    under Medicaid.\94\
    ---------------------------------------------------------------------------
        \94\This provision is modeled after the current Centers for
    Medicare and Medicaid Services State Children's Health Insurance
    Program regulation prohibiting cost-sharing for Indian children (42
    C.F.R. Section 457.535).
    ---------------------------------------------------------------------------
        Indian tribes have strongly advocated that this policy
    waiving Medicaid co-pays reflects the federal trust obligation
    for Indian health wherein the health care has been ``pre-
    paid''--for example, by the treaty agreements exchanging tribal
    lands for health care. As additional justification, the Indian
    tribes contend that this policy is not unusual to the Medicaid
    system, since other Medicaid policies reflect that federal
    obligation. An example of this is the 100% FMAP or Federal
    Matching Assistance Percentage, wherein the federal government
    provides 100% of the reimbursement to states of Medicaid
    reimbursements for services provided by the IHS or tribal
    health programs.
        Moreover, Indian tribes contend that the waiver of the co-
    pay is necessary to create incentives to enroll in Medicaid.
    Recognizing the federal obligation for Indian health care, the
    IHS, tribal and urban health programs do not charge the Indian
    patients cost-sharing for participating in the Indian health
    system to which Medicaid provides reimbursements. Charging the
    Indian patient a Medicaid co-pay will create a disincentive to
    enroll, essentially barring that Indian patient's access to
    Medicaid; as a result, the overall Indian health budget, along
    with the ability to provide additional services, may suffer. On
    the other hand, waiver of the co-pay will continue to encourage
    Indian patients to enroll in Medicaid programs, thus
    ``stretching'' IHS appropriated dollars.
        The Committee is aware of concerns that cost sharing
    discourages overutilization of health care services, which
    should be of particular concern to a system which is
    overburdened already. However, this concern may be addressed in
    several ways.
        Cost-sharing would not achieve the intended purpose of
    modifying behavior to avoid overutilization within the Indian
    health system. Overutilization assumes that there are otherwise
    adequate levels of services available to a population of non-
    overutilizers. Punitive or disincentive measures will not work
    if the service is not available or delayed. Services being
    unavailable or delayed have been documented by the GAO
    study,\95\ and the IHS Level of Need Funded (LNF) Study. The
    data in the GAO study reported that many Indian people are not
    seeking health care services until it is too late. There was no
    evidence in this GAO report that overutilization of the health
    care services occurred at the Indian health programs.
    ---------------------------------------------------------------------------
        \95\GAO Report No. GAO-05-789, (August, 2005).
    ---------------------------------------------------------------------------
        The data in the LNF Study also suggests that many Indian
    patients may have to delay seeking health care because services
    are rationed, rather than available for every health care need.
    In other words, Indian patients are not running to the clinic
    for every sniffle, but may wait until their health care needs
    become emergent problems. Thus, it is unlikely that
    overutilization occurs, so there is no problem that the cost-
    sharing would obviate. Imposing cost-sharing, on the other
    hand, may serve to further exacerbate the problem of delaying
    health care by requiring a co-pay by Indian patients who can
    ill afford it.
        Removing barriers to enrollment will enable Indian patients
    to enroll in Medicaid, and the ensuing Medicaid reimbursements
    will assist the Indian health program in providing more
    services, thereby diminishing the potential of overburdening
    the system. Cost-sharing is, in reality, cost-shifting. If
    Indian patients are eligible and qualify for Medicaid, then the
    patient should take advantage of the available program. By not
    enrolling, the cost that should be borne by Medicaid continues
    to strain the IHS budget, which has been documented to be
    insufficient to meet the needs of Indian communities.
        Consequently, S. 1200 continues the policy and provisions
    regarding Medicaid co-pays that were reported favorably by the
    Senate Finance Committee in S. 3524 during the 109th Congress.
        Non-Eligibles. Congress has recognized that ``without a
    proper health status, the Indian people will be unable to fully
    avail themselves of the many economic, educational, and social
    programs already directed to them.''\96\ Providing services to
    Indian people improves the health of Indians in a direct
    manner.
    ---------------------------------------------------------------------------
        \96\Senate Report 94-133, at 23.
    ---------------------------------------------------------------------------
        However, protecting the health of Indians requires
    attention to issues other than direct services to Indians. In
    the 1800s, services such as vaccinations were provided to
    Indians located near forts to protect the health of
    soldiers.\97\ Now the tables are turned. Under certain
    circumstances, individuals not otherwise eligible for Indian
    health care may receive a limited scope of health services
    under the Act to protect the health of Indians.
    ---------------------------------------------------------------------------
        \97\See American Indian Policy Review Commission, Task Force Six,
    Final Report to the Commission, Vol. 6, at 28.
    ---------------------------------------------------------------------------
        Serving ``non-eligibles'' for these purposes comports with
    the Administration's goals of promoting ``healthy Indian . . .
    communities''\98\ and ``including new approaches to delivering
    care.''\99\ Serving non-eligibles has been a policy of the Act
    for many years and it reflects a logical and reasonable
    approach to protect Indian health.
    ---------------------------------------------------------------------------
        \98\S. Hrg. 109-162, at 585 (statement of Dr. Grim, Director, U.S.
    Department of Health and Human Services, Indian Health Service).
        \99\Id. at 589.
    ---------------------------------------------------------------------------
        For example, the Act provides that services may be provided
    to a non-eligible pregnant woman carrying an Indian's child. 25
    U.S.C. 1680c(c)(3) (Section 807(d)(3) of S. 1200). In addition,
    services may be provided to prevent the outbreak of
    communicable diseases such as tuberculosis. 25 U.S.C.
    1680c(c)(2) (Section 807(d)(2) of S. 1200).
        In including these ``non-eligible individuals'' in the
    service delivery system, Congress has set forth considerations
    for the IHS and Indian tribes to address prior to providing the
    services--the ``two-part determination'' contained at 25 U.S.C.
    1680c(b)(1)(A):
              (i) the provision of such health services will not
            result in a denial or diminution of health services to
            eligible Indians; and
              (ii) there is no reasonable alternative health
            facility or services, within or without the service
            area of such service unit, available to meet the health
            needs of such individuals.
        However, the Committee is aware that questions have arisen
    regarding how the two-part determination applies to Indian
    tribes with contracts or compacts under ISDEAA.
        Where services are directly provided by the IHS, the Indian
    tribe(s) served by the Service Unit and the IHS jointly make
    the two-part determination (25 U.S.C. 1680c(b)(1)(A)). Section
    807 of S. 1200 provides that, for programs administered by an
    Indian tribe pursuant to a contract or compact under the
    ISDEAA, the Indian tribe is authorized to provide services to
    non-eligibles, but ``shall take into account'' the two-part
    determination.
        Congress has made it clear that the determination shall be
    made in both instances: in the case of direct services it is
    made by both IHS and the Indian tribes and, in the case of
    ISDEAA contracts or compacts, by Indian tribes. Congress did
    not provide in the Act express substantive or procedural
    provisions governing how the determinations should be made,
    given the innumerable variations in circumstances for the
    Indian communities.
        However, Section 807 does provide some guidance on how the
    parties may determine whether there will be no diminution of
    services. For example, the non-eligibles receiving services
    ``shall be liable for payment of such health services under a
    schedule of charges prescribed by the Secretary'' (25 U.S.C.
    1680c(b)(2)(A)). In other words, no diminution may be
    experienced if the funded used to serve these people is
    replaced by other funding.
        In addition, health services may be provided to indigent
    non- eligibles if there is a reimbursement agreement with the
    State or local governments. These provisions, however, do not
    limit the ability of either the IHS or Indian tribes to include
    additional considerations in determining whether services would
    be decreased. Other budgetary factors, delays in services, and
    appointment waiting times,\100\ are all other considerations
    that may be appropriate, depending on the particular
    circumstances.
    ---------------------------------------------------------------------------
        \100\See GAO Report No. GAO-05-789.
    ---------------------------------------------------------------------------
        Likewise, when assessing reasonable alternatives, the IHS
    and Indian tribes may be confronted by factors such as remote
    locations, distances to other health facilities and other
    unique difficulties, which render other health care
    alternatives unavailable. Questions surrounding what is
    available should be placed in the context of the following
    policy considerations. First, services under this Act are for
    the ultimate protection of Indian health. Second, the IHS and
    tribal health programs are the payors of last resort which
    means, in this situation, that all other avenues of obtaining
    health services should be exhausted by the non- eligible
    individual prior to seeking assistance from either IHS or the
    tribal health programs.
        The Committee has been informed that some health providers
    may refuse to serve Medicaid beneficiaries, thus making any
    other health service alternatives unavailable. In those
    situations, if good faith efforts have been made to obtain
    services and all avenues have been exhausted, it appears that
    there may be an arguable case of unavailability.
        When making these determinations, Indian tribal leaders are
    placed in a difficult situation. On the one hand, the federal
    obligation for Indian health--which the Indian tribe is
    administering--is secured for the benefit of Indians.
    Authorizing services for non-eligibles is a determination not
    made lightly by Indian tribal leaders. On the other hand,
    withholding services from these non-eligibles under the limited
    circumstances enumerated in this Act may serve to do harm to
    Indian people by not eliminating general health hazards.
        Evaluations were left in S. 1200 to the IHS and Indian
    tribes based on their particular circumstances and, if
    appropriate, could be developed more fully through negotiated
    rulemaking or consultation.

                          Section-by-Section Analysis

        A significant portion of current law has been carried
    forward by S. 1200 and reorganized in the various titles
    according to subject matter. S. 1200 also adds several new
    provisions to current law which may (1) amend current law, such
    as turning a demonstration project into a permanent program,
    (2) clarify or make small additions, such as including Tribal
    Organizations in various sections, or (3) introduce brand new
    programs to the Indian health care system, such as Indian youth
    suicide prevention, intervention and treatment through the use
    of telemedicine, and convenient care services.
        The following section-by-section analysis will, where
    relevant, identify whether current law has been changed
    followed by an explanation of the current law to be
    reauthorized by S. 1200. In addition, the codified section in
    current law is also noted to provide ease of reference.

    Section 1. Short title; table of contents

        Section 1 provides that this Act may be cited as the
    ``Indian Health Care Improvement Act Amendments of 2007,'' and
    contains the table of contents.

                       TITLE I--AMENDMENTS TO INDIAN LAWS

        The provisions of Title I are within the jurisdiction of
    the Senate Indian Affairs Committee.

    Section 101. Indian Health Care Improvement Act amended

        This section sets forth a host of provisions which
    incorporate provisions of current law and make amendments to
    the Act.

    Section 1. Short title; table of contents

        This Act may be cited as the ``Indian Health Care
    Improvement Act.'' Section 1 also sets for the table of
    contents for Title I.

    Section 2. Findings

        Section 2 sets out Congressional findings for the Act,
    which indicate that the health levels of Indians are below that
    of the rest of the U.S. population and that the provision of
    health care is consonant with the Federal relationship and
    responsibility to Indian people.
        Amendments: This section maintains current law.
        Current Law: This section is Section 1601 of current law.

    Section 3. Declaration of national Indian health policy

        This section declares national policy, in fulfillment of
    the special trust responsibilities and legal obligations to
    Indians, to assure the highest possible health status for and
    raise the health status of Indians and Urban Indians through
    the provision of health services.
        Amendments: This section amends current law by (1)
    replacing the enumerated list of health level objectives with
    the goals contained in the Healthy People 2010 national health
    agenda; and (2) adding new language to (a) add trust to the
    responsibilities being fulfilled by the national policy, (b)
    allow Indians to set their priorities according to their needs,
    (c) increase the health profession degrees awarded to Indians
    so the levels of Indian health professionals in each Service
    Area is at least the level of the general population, (d)
    require consultation with Indian Tribes, Tribal Organizations
    and Urban Indian Organizations, consistent with the policy of
    Indian self-determination, and (e) provide funding to Indian
    tribal programs and facilities consistent with levels of IHS
    programs and facilities.
        Current Law: This section is Section 1602 of current law.

    Section 4. Definitions

        Section 4 provides definitions for terms used throughout
    the Act.
        Amendments: This section maintains current law and adds
    several new definitions. Assistant Secretary, behavioral
    health, tribal college or university, telehealth, contract
    health service, and telemedicine are examples of new
    definitions not now in current law.
        Current Law: Section 1603 of current law provides
    definitions for terms used throughout the Act.

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

    Section 101. Purpose

        This section states the purpose of this title, which is to
    increase the number of Indians entering health professions and
    providing health services, and to assure an optimum supply of
    health professionals to provide health services to Indians.
        Amendments: This section maintains current law and adds
    language indicating congressional intent to maximize the
    number, and assure an optimum (not merely adequate) supply, of
    health professionals in the Indian health system.
        Current Law: Section 1611 of current law states the purpose
    of increasing the number of Indian health professionals and
    assuring an adequate supply of health professionals to provide
    health services to Indians.

    Section 102. Health professions recruitment program for Indians

        This section authorizes grants for recruitment programs,
    including identifying Indians with potential for entering
    health professions, publicizing sources of financial aid, and
    establishing programs to facilitate enrollment in applicable
    courses of study. This section also addresses funding
    applications and amount of funding to be provided, as well as
    outlining the eligibility for these programs.
        Amendments: This section maintains current law.
        Current Law: This section is Section 1612 of current law.

    Section 103. Health professions preparatory scholarship program for
            Indians

        Section 103 authorizes scholarships to Indians for
    compensatory preprofessional education, as well as pregraduate
    education leading to a baccalaureate degree in a preparatory
    field for a health profession. This section specifies certain
    conditions on these scholarships which include costs which may
    be covered by the scholarships, and prohibits denial of a
    scholarship based solely on scholastic achievement if applicant
    has already been admitted or maintains good standing at an
    accredited institution, or if the applicant is eligible for
    assistance under another federal program.
        Amendments: This section maintains current law and adds new
    provisions, authorizing extensions of pregraduate scholarship
    award terms up to 2 years, according to Secretarial
    regulations, and authorizing regulations for determining part-
    time equivalents for the compensatory preprofessional
    scholarships.
        Current Law: This section is Section 1613 in current law.

    Section 104. Indian health professions scholarships

        Section 104 authorizes scholarships to Indians who are
    enrolled full- or part-time in accredited schools, pursuing
    courses of study in the health professions. Such scholarships
    are designated as Indian Health Scholarships. The section
    further sets forth how the funding for these scholarships is to
    be allocated and addresses all the requirements of the active
    duty service obligation incurred as a result of the
    scholarship, including breach of contract situations.
        Amendments: This section maintains current law and adds new
    provisions that (1) require a year-for-year service obligation
    for scholarship recipients; (2) require Secretarial guidelines
    for fulfilling the service obligation in private practice; and
    (3) allow a recipient to fulfill the service obligation by
    teaching in a tribal college or university nursing program if
    health services to Indians are not diminished
        Current Law: This section is Section 1613a of current law.

    Section 105. American Indians into psychology program

        This section authorizes grants of not more than $300,000 to
    each of 9 colleges and universities for developing and
    maintaining Indian psychology career recruitment programs,
    including a Quentin N. Burdick Program Grant at the University
    of North Dakota. This section directs the Secretary to issue
    regulations for competitive funding, and specifies conditions
    of the grants and active duty service requirements. $2.7
    million is authorized for each of FY 2008 through 2017.
        Amendments: This section maintains current law and adds new
    language which (1) sets the number of colleges or universities
    that may receive grants from at least 3 to 9, and (2)
    establishes a maximum grant amount of $300,000, for a total of
    $2.7 million for each of FY 2008 through 2017.
        Current Law: The section is Section 1621p of current law.

    Section 106. Scholarship programs for Indian tribes

        Section 106 authorizes the Secretary to make funds
    available to Tribal Health Programs for the purpose of
    educating Indians to serve as health professionals in Indian
    communities. The requirements for receiving such funds; the
    course of study; contract requirements; specific parameters for
    a breach of contract; the relationship of a scholarship under
    this section to the Social Security Act; and conditions of
    continuance of funding are all specified in this section. The
    recipient is required to fulfill service obligations and use
    the scholarship for tuition and reasonable education or living
    expenses. The recipient cannot discriminate against patients
    who receive assistance under Titles XVIII and XIX of the Social
    Security Act.
        Amendments: This section maintains current law and adds new
    language which (1) amends the source of funds for the
    scholarship costs by allowing 20% to be from any source instead
    of only non-federal sources; (2) requires that licensing and
    educational requirements be met for all health professions, not
    only for the doctor and nursing professions; (3) provides that
    the scholarship may allow the recipient to serve in another
    Service Area, provided the Tribal Health Program and Secretary
    approve and services are not diminished to Indians in the
    Service Area where the Tribal Health Program providing the
    scholarship is located; and (4) adds Title XXI of the Social
    Security Act to the non- discriminatory provisions.
        Current Law: This section is Section 1616m of current law.

    Section 107. Indian Health Service extern programs

        Section 107 gives preference for employment with the
    Service, a Tribal Health Program, Urban Indian Organization or
    other agencies within the Department, to any recipient of a
    scholarship pursuant to section 104 or 106. The section
    specifies that such employment does not count toward any active
    duty service obligation. It specifies the timing and length of
    employment and exempts the program from any competitive
    personnel system or agency personnel limitation. The section
    further specifies that an individual employed under this
    section will receive practical experience in the health
    profession in which he or she is engaged in study.
        Amendments: This section maintains current law and adds the
    following new provisions: (1) extends the extern program to
    Tribal Health Programs, Urban Indian Organizations or urban
    Indian health providers (on a discretionary basis) or other
    Department agencies, instead of only the IHS; and (2) gives the
    extern, including an extern in a high school program, a
    preference for employment with the IHS, instead of entitling
    them to employment.
        Current Law: This section is Section 1614 of current law.

    Section 108. Continuing education allowances

        This section permits the Secretary to provide programs or
    allowances to (a) transition in to an Indian Health Program,
    including licensing, board or certification examination and
    technical assistance, in fulfilling service obligations, and
    (b) health professionals employed in an Indian Health Program
    to enable them to take leave of their duty stations for a
    period of time each year for professional consultation and
    refresher training courses.
        Amendments: This section maintains current law, but also
    deletes the set-aside of not more than $1 million for
    postdoctoral training contained in current law, and adds
    language which extends the continuing education allowances to
    Tribal Health Programs and Urban Indian Organizations, in
    addition to the IHS, and includes all health professionals,
    rather than specified select health professionals.
        Current Law: This section is Section 1615 of current law.

    Section 109. Community Health Representative Program

        Section 109 authorizes the Community Health Representative
    Program for training and using Indians as community health
    representatives. The section specifies the duties of the
    Service regarding this program, including providing a high
    standard of training for Community Health Representatives to
    ensure that these representatives provide quality health
    services to Indian communities served by this program. This
    program may also promote traditional health care practices
    consistent with IHS standards for health care.
        Amendments: This section maintains current law, and adds
    language which formally identifies the health paraprofessionals
    as Community Health Representatives (CHRs) and extends the use
    of CHRs to Tribal Health Programs and Urban Indian
    Organizations as well as IHS programs.
        Current Law: The section is Section 1616 of current law.

    Section 110. Indian Health Service Loan Repayment Program

        This section directs the Secretary to establish and
    administer the Service Loan Repayment Program in order to
    ensure an adequate supply of trained health professionals
    needed to maintain accreditation of, and provide health care
    services to Indians through, Indian Health Programs and Urban
    Indian Organizations. The section includes provisions
    addressing eligibility for the program; application
    information; priorities; recipient contracts; deadlines for
    decisions on applications; a loan repayment program; a waiver
    from any employment ceiling; a recruitment program; non-
    applicability of Section 214 of the Public Health Service Act
    (which concerns employees or officers being assigned to other
    agencies) during the period of obligated service; assignment of
    individuals; breach of contract; waiver or suspension of
    obligation; and the requirement of an annual report to Congress
    under Section 801.
        Amendments: This section maintains current law. In
    addition, it (1) eliminates the set-asides during FY 1993-1995
    for nursing and mental health professions; and (2) establishes
    priorities among applications rather than requiring the
    priorities be subject to the list of positions established by
    the Secretary, and sets a 21-day notice requirement instead of
    merely prompt notice.
        Current Law: This section is Section 1616a of current law.

    Section 111. Scholarship and Loan Repayment Recovery Fund

        Section 111 establishes an Indian Health Scholarship and
    Loan Repayment Recovery Fund within the Treasury of the United
    States. The section specifies the use of these funds, the
    investment of the funds, and the sale of obligations by the
    Secretary of the Treasury.
        Amendments: This section maintains current law, and adds
    provisions expanding the source of funds for this Recovery Fund
    to include funds collected from individuals for breach of
    contract under the scholarship or loan repayment programs and
    interest, in addition to appropriations. Tribal Health Programs
    may also use payments received to provide scholarships, in
    addition to the current uses of recruitment and employment of
    health care professionals. The Secretary of Health and Human
    Services may now determine what amounts are not required to
    meet current withdrawals from the Fund, rather than the
    Secretary of the Treasury, as in current law.
        Current Law: This section is Section 1616a-1 of current
    law. It establishes an Indian Health Scholarship and Loan
    Repayment Recovery Fund within the Treasury of the United
    States, wherein funds collected for breaches of contractual
    obligations under the IHS or tribal scholarships or loan
    repayment programs are placed.

    Section 112. Recruitment activities

        Section 112 permits the Secretary to reimburse certain
    travel expenses to health professionals seeking positions with
    Indian Health Programs or Urban Indian Organizations. Potential
    candidates for contracts under section 110 and their spouses
    are all eligible for such reimbursement of travel. In addition,
    this section requires the Secretary to assign one individual in
    each Area Office to have full-time responsibility for
    recruitment activities.
        Amendments: This section maintains current law and adds
    language to allow reimbursement for health professionals
    seeking positions with Tribal and Urban Indian Health Programs,
    in addition to the IHS.
        Current Law: This section is Section 1616b of current law.

    Section 113. Indian recruitment and retention program

        Section 113 requires the Secretary to fund innovative
    demonstration projects to enable Tribal Health Programs and
    Urban Indian Organizations to recruit, place, and retain health
    professionals to meet their staffing needs. The section also
    specifies that any Tribal Health Program or Urban Indian
    Organization is eligible to apply for these funds.
        Amendments: This section maintains current law and adds
    language which (1) sets a time limit of three years for
    demonstration projects funded under this section instead of an
    open-ended timeframe under current law; and (2) clarifies that
    the entities eligible to compete are Tribal Health Programs and
    Urban Indian Organizations.
        Current Law: This section is Section 1616c of current law.

    Section 114. Advanced training and research

        This section establishes a demonstration project to enable
    health professionals who have worked in an Indian Health
    Program or Urban Indian Organization for a substantial period
    of time to pursue advanced training or research areas of study,
    where a need exists. Each individual who participates shall
    incur a service obligation. The section also specifies equal
    opportunity for participating in the program.
        Amendments: This section maintains current law and adds
    language which limits the advanced training or research
    opportunities to health professionals who have worked for the
    IHS, tribal or urban Indian health programs for a substantial
    period of time, instead of merely being employed by one of
    these programs at the time of application.
        Current Law: This section is Section 1616d of current law.

    Section 115. Quentin N. Burdick American Indians into Nursing Program

        Section 115 authorizes the Quentin N. Burdick American
    Indians into Nursing Program for the purpose of increasing the
    number of nurses, nurse midwives, and nurse practitioners who
    deliver health care services to Indians. The section specifies
    potential grant recipients; how grants may be used; information
    which must be included in applications for the grant;
    preferences for grant recipients; establishment and maintenance
    of a program at the University of North Dakota; and an active
    duty service obligation.
        Amendments: This section maintains current law and adds
    language which (1) includes advanced practice nurse programs in
    addition to nurse practitioners; (2) authorizes grants for
    midwife or nursing programs at tribal colleges and universities
    or, in their absence, other colleges and universities, instead
    of only at the other public or private institutions; and (3)
    includes tribal colleges and universities in the preferences
    among grant applicants.
        Current Law: This section is Section 1616e of current law.

    Section 116. Tribal cultural orientation

        This section requires certain employees of the Service who
    serve Indian Tribes in each Service Area to receive instruction
    in the history and culture of the Indian Tribes they serve. The
    section requires that the program be developed in consultation
    with the affected Indian entities, be implemented through
    tribal colleges or universities, include instruction in
    American Indian studies, and describe the use and place of
    traditional health care practices of the Indian Tribes in the
    Service Area.
        Amendments: This section maintains current law and adds
    language which (1) ensures that employees in each Service Area
    obtain cultural orientation, rather than merely establishing a
    program for cultural orientation; (2) requires the program to
    include instruction on the relationship of the Indian Tribes
    with the IHS, rather than simply a history of the IHS, and a
    description of the traditional health care practices of the
    Indian tribes in the Service Area; and (3) requires
    consultation with affected Tribes, Tribal Organizations and
    Urban Indian Organizations.
        Current Law: This section is Section 1616f of current law.

    Section 117. INMED Program

        Section 117 authorizes the Secretary to provide grants to
    colleges and universities to maintain and expand the Indian
    health careers recruitment program known as the Indians Into
    Medicine Program (INMED). The Quentin N. Burdick Grant at the
    University of North Dakota is to be one of the authorized
    grants. This section also specifies requirements for
    institutional applicants for these grants.
        Amendments: This section maintains current law and adds
    language which (1) authorizes grants to an unspecified number
    of colleges or universities instead of the previous mandate of
    at least 3 schools; (2) clarifies that the regulations govern
    the grants, including substantive provisions, such as criteria
    and application requirements, rather than govern only the
    competitive award process; and (3) eliminates an old 1988
    requirement of a report to Congress on the program and
    recommendations for changes.
        Current Law: This section is Section 1616g of current law.

    Section 118. Health training programs of community colleges

        This section requires the Secretary to award grants to
    accredited, accessible community colleges to assist in
    establishing health profession education leading to a degree or
    diploma for individuals who desire to practice such profession
    on or near a reservation or in an Indian Health Program. The
    Secretary is also required to award grants to accredited,
    accessible community colleges that already have these programs.
    The Secretary must provide technical assistance to encourage
    community colleges to establish and maintain such programs. Any
    program receiving assistance under this section is required to
    provide advanced training for health professionals. Grant award
    priority is provided to tribal colleges and universities in
    Service Areas where they exist.
        Amendments: This section maintains current law and adds
    language which (1) recognizes accredited and accessible
    community colleges as eligible recipients of grants; (2)
    requires the colleges to have a relationship with a hospital,
    rather than merely having access to a hospital; (3) requires
    Indian preference for program participants; (4) increases the
    ceiling amount of the grant from $100,000 to $250,000; and (5)
    establishes priority for tribally-controlled colleges in
    Service Areas where they exist, if other requirements in the
    section are met.
        Current Law: This section is Section 1616h of current law.

    Section 119. Retention bonus

        Section 119 permits the Secretary to provide retention
    bonuses to any health professional where recruitment or
    retention is difficult or is needed by Indian Health Programs
    and Urban Indian Organizations, if the individual has completed
    2 years of employment with an Indian Health Program or Urban
    Indian Organization or any service obligation from federal
    scholarships or loan repayment programs, and enters into an
    agreement with an Indian Health Program or Urban Indian
    Organization for continued employment for a period of not less
    than 1 year. Rates for retention bonuses may cover multiple
    years, but not exceed an annual rate of $25,000. Refunds shall
    be required if the health professional does not complete the
    term of service under any retention agreement, unless the
    default is not the fault of the individual.
        Amendments: This section maintains current law and adds
    language expanding the bonuses (1) to any health professional,
    rather than only doctors and nurses, so language specifying
    funding set-asides between these 2 professions has been
    deleted; and (2) to health professionals employed by the tribal
    or urban health programs, rather than employed only by the
    Service. Language also eliminates the current requirement that
    the retention bonus be paid at the beginning of the term of
    service.
        Current Law: This section is Section 1616j in current law.

    Section 120. Nursing residency program

        This section establishes a program to enable Indians who
    are nurses working for an Indian Health Program or Urban Indian
    Organization to pursue advanced training. The participants are
    required to enter a service obligation to serve in an Indian
    Health Program or Urban Indian Organization. The program shall
    include a combination of education and work study leading to
    either an associate or bachelor's degree or advanced degrees or
    certifications.
        Amendments: This section maintains current law and adds
    language which establishes this program for Indian nurses and
    includes advanced degrees or certifications in nursing or
    public health as eligible programs, instead of a Master's
    degree, as appropriate post-baccalaureate training.
        Current Law: This section is Section 1616k of current law.

    Section 121. Community Health Aide Program

        Section 121 directs the Secretary to develop and operate a
    Community Health Aide Program in Alaska. Requirements are
    specified for the Alaska program. Dental Health Aide Therapists
    under the Program would be prohibited from performing all oral
    and jaw surgeries except pulpal therapy or extraction of adult
    teeth after consultation with a licensed dentist in a dental
    emergency. In addition, the Secretary is directed to establish
    a neutral panel to conduct a study of the dental health aide
    therapist services provided by the Community Health Aide
    Program. Specifications of the study, which will lead to a
    report to Congress, are delineated. This section also allows
    the Secretary to establish a national Community Health Aide
    Program, which shall not include dental health aide therapist
    services, and shall not reduce funds for the Alaska program.
        Amendments: This section maintains current law and adds
    provisions which (1) require the Secretary to establish a
    neutral panel, whose membership is also set forth in this
    section, to study the dental health aide therapist program in
    Alaska Native communities and to submit a report on the study
    to appropriate Congressional Committees and (2) authorizes the
    expansion of the Community Health Aide Program, except for the
    dental health aide therapist program, to Indian communities in
    the lower 48 states.
        Current Law: This section is Section 1616l of current law.

    Section 122. Tribal Health Program administration

        This section requires the Secretary to provide training for
    Indians in the administration and planning of Tribal Health
    Programs.
        Amendments: This section maintains current law and adds
    language which specifies that the training shall be for
    individuals who are Indian.
        Current Law: This section is Section 1616n of current law.

    Section 123. Health professional chronic shortage demonstration
            programs

        This section permits the Secretary to fund demonstration
    programs for Tribal Health Programs to address the chronic
    shortages of health professionals. Each demonstration program
    shall incorporate a program advisory board, which is to be
    composed of representatives from the Indian Tribes and Indian
    communities which are served by the program.
        Amendments: This section amends current law by changing a
    single pilot program at the School of Medicine at the
    University of South Dakota to address health professional
    shortages into a national demonstration project.
        Current Law: This section is Section 1616o in current law.
    Current law authorizes the Secretary to make a grant to the
    School of Medicine at the University of South Dakota to fund a
    pilot program on an Indian reservation at one or more Service
    Units in South Dakota to address the chronic manpower shortages
    in the Aberdeen Area of the IHS.

    Section 124. National Health Service Corps

        This section prohibits the Secretary from removing a member
    of the National Health Service Corps from an Indian Health
    Program or Urban Indian Organization or withdrawing funding
    used to support such member, unless the Secretary ensures that
    Indians will experience no reduction in services. The section
    also exempts Corps scholars qualifying for the Commissioned
    Corps in the United States Public Health Service from full-time
    equivalent limitations when serving as a commissioned corps
    officer in a Tribal Health Program or an Urban Indian
    Organization.
        Amendments: This section maintains current law and adds
    Urban Indian organizations. Language which exempts National
    Health Service Corps scholars qualifying for the Commissioned
    Corps in the United States Public Health Service from full-time
    equivalent limitations when serving as a commissioned corps
    officer in a Tribal Health Program or an Urban Indian
    Organization is new to current law.
        Current Law: This section is Section 1680b of current law.

    Section 125. Substance abuse counselor educational curricula
            demonstration programs

        Section 125 allows the Secretary to enter into contracts
    with or make grants to accredited colleges and universities
    (including tribal) to establish demonstration programs
    developing curricula for substance abuse counseling. Duration
    and renewal of the grants is specified. The section also states
    the criteria for review and approval of the applications;
    requires the Secretary to provide technical and other
    assistance to grant recipients; requires the Secretary to
    submit an annual report to the President under section 801; and
    defines the term ``educational curriculum.''
        Amendments: This section maintains current law, and adds
    language including accredited and accessible qualifications for
    the community colleges eligible for these programs and
    extending the initial grant period from one year to three years
    and the renewal periods from one year to two years.
        Current Law: This section is Section 1665j of current law.

    Section 126. Behavioral health training and community education
            programs

        This section requires the Secretary, with the Secretary of
    the Interior and in consultation with Indian Tribes and Tribal
    Organizations, to conduct a study and compile a list of certain
    types of staff positions within the Bureau of Indian Affairs,
    the Service, Indian Tribes, Tribal Organizations and Urban
    Indian Organizations, which should include training in any
    aspect of mental illness, dysfunction, or self-destructive
    behavior.
        The Secretary is then required to provide training criteria
    appropriate for each type of position and ensure that this
    training is provided. Upon request of the appropriate Indian
    entity, the Secretary is required to develop and implement a
    program of community education on mental illness, as well as to
    provide technical assistance to tribal entities to obtain and
    develop community education materials.
        Within 90 days of enactment of this Act, the Secretary is
    required to develop a plan to increase behavioral health
    services by at least 500 staff positions within 5 years, with
    at least 200 of such positions being devoted to child,
    adolescent, and family services.
        Amendments: This section maintains current law and (1) adds
    Tribal Organizations and Urban Indian Organizations as
    participants in the program; (2) clarifies that Tribal
    Organizations are to be part of the consultation process; (3)
    changes the focus from solely on mental health to behavioral
    health; and (4) eliminates the requirement that the staff be
    assigned primarily to the IHS Service Units.
        Current Law: This section is Section 1621h(d) of current
    law.

    Section 127. Authorization of appropriations

        Section 127 authorizes to be appropriated such sums as may
    be necessary to carry out this title for each fiscal year
    through 2017.
        Amendments: The section updates the authorization period
    through fiscal year 2017, instead of fiscal year 2000.
        Current Law: This section is Section 1616p of current law.

                           TITLE II--HEALTH SERVICES

    Section 201. Indian Health Care Improvement Fund

        This section authorizes the use of funds for the purposes
    of eliminating the deficiencies in health status and resources
    for tribes; eliminating backlogs and meeting the needs in
    health care services; eliminating the inequities in funding for
    direct care and contract health service programs; and
    augmenting the ability of the Indian Health Service to meet its
    various responsibilities. Funding authorized by this section
    may not be used to offset appropriated funds and must be used
    to improve the health status and reduce the resource
    deficiencies of tribes.
        This section also defines ``health status and resource
    deficiency'' and requires that Tribal Health Programs be
    equally eligible for funds as programs administered by the
    Indian Health Service. A report is required to be submitted to
    Congress 3 years after enactment which addresses the current
    health status and resource deficiency for each Service Unit.
    Funds appropriated under this section are to be included in the
    base budget of the Indian Health Service for determining
    appropriations in subsequent years.
        Nothing in this section is intended to diminish the primary
    responsibility of the Indian Health Service to eliminate
    backlogs in unmet health care, or to discourage additional
    efforts of the Service to achieve equity among Tribes and
    Tribal Organizations.
        Funds appropriated under this section are to be designated
    as the ``Indian Health Care Improvement Fund.''
        Amendments: This section maintains current law and adds
    provisions clarifying that the Secretary may expend funds
    either directly or through contracts or compacts under the
    Indian Self-Determination and Education Assistance Act, as well
    as provisions regarding the use of telehealth and telemedicine.
    Language has been added specifying the kinds of injury
    prevention programs that may be offered.
        Current Law: This section is Section 1621 of current law.

    Section 202. Catastrophic Health Emergency Fund

        Section 202 establishes the Catastrophic Health Emergency
    Fund (CHEF), which is to be administered by the Secretary
    through the headquarters of the Indian Health Service in order
    to meet the extraordinary medical costs associated with the
    treatment of victims of disasters or catastrophic illnesses. No
    part of the CHEF or the administration thereof is to be subject
    to contract or grant, nor shall these funds be apportioned on
    an Area Office, Service Unit, or other similar basis. The
    Secretary is required to promulgate regulations for the
    administration of these funds. This section prohibits funds
    appropriated to CHEF from being used to offset or limit other
    appropriations made to the Indian Health Service. It also
    requires that all reimbursements to which the Service is
    entitled from any source by reason of treatment rendered to any
    victim of a disaster or catastrophic illness the cost of which
    was paid from CHEF shall be deposited into CHEF.
        Amendments: This section maintains current law.
        Current Law: This section is Section 1621a in current law.

    Section 203. Health promotion and disease prevention services

        This section finds that health promotion and disease
    prevention activities improve health and well-being and reduce
    the expenses for health care. It requires the Secretary to
    provide these services and, with input from the affected Tribal
    Health Programs, to report to Congress on an evaluation
    statement of the status, capacity and resources needed to
    promote health and prevent disease.
        Amendments: This section maintains current law, but moves
    the definition of health promotion and disease prevention to
    the definitions section and adds Congressional findings.
        Current Law: This section is Section 1621b of current law.

    Section 204. Diabetes prevention, treatment, and control

        Section 204 requires the Secretary to determine the
    incidence of diabetes and its complications among Indians and
    the measures needed to prevent, treat and control this disease.
    The Secretary is also required, when medically indicated and
    with informed consent, to screen Indians for diabetes and for
    conditions which indicate a high risk for diabetes.
        The Secretary is required to continue to fund model
    diabetes projects and dialysis programs. To the extent that
    funding is available, the Secretary is required to work with
    each Area Office to consult with Tribes and Tribal
    Organizations regarding diabetes programs; establish patient
    registries in Area Offices; and ensure that data collected are
    disseminated to other Area Offices, subject to privacy laws.
    The Secretary is also allowed to maintain diabetes control
    officers, but if these positions and activities are
    administered by the Tribes or Tribal Organizations, then the
    funding and activities would not be divisible under the Indian
    Self-Determination and Education Assistance Act.
        Amendments: This section maintains current law and (1) adds
    (a) Tribal Organizations as eligible participants in these
    programs, (b) effective ongoing monitoring of disease
    indicators, (c) the requirement that screening shall be to the
    extent medically indicated and with informed consent, and (d)
    funding for dialysis programs; (2) changes the model diabetes
    projects into permanent programs to be continued along with any
    new programs developed with recurring funding; and (3) still
    allows for diabetes control officers in each Area Office, but
    provides that if these positions and activities are
    administered by the Tribes or Tribal Organizations, then the
    funding and activities would not be divisible under the Indian
    Self-Determination and Education Assistance Act.
        Current Law: This section is Section 1621c of current law.

    Section 205. Shared services for long-term care

        This section allows the Secretary to enter into funding
    agreements with Tribes and Tribal Organizations for the
    delivery of long-term care services to Indians. Contents of
    these funding agreements are specified. Any nursing facility
    funded under this section must meet the requirements for such
    facilities under section 1919 of the Social Security Act. In
    addition, the Secretary is required to provide necessary
    technical and other assistance to enable applicants to comply
    with the provisions of this section. The Secretary shall
    encourage the use of existing underused facilities or allow the
    use of swing beds for long-term or similar care.
        Amendments: This section amends current law by changing a
    demonstration project into a permanent program and adding new
    provisions which (1) include health care services associated
    with long- term care provided in a facility for Indians; and
    (2) encourage the use of existing underused facilities or allow
    the use of swing beds for long-term or similar care.
        Current Law: This section is Section 1680l of current law.

    Section 206. Health services research

        This section requires the Secretary to make funding
    available for both clinical and nonclinical research to further
    the delivery of Indian health services, and to coordinate the
    activities of other agencies within the Department to address
    this need. Tribal Health Programs are to be given equal
    opportunity to compete for these research funds. The Secretary
    shall also periodically evaluate the impact of research
    conducted under this section, and disseminate to Tribal Health
    Programs information regarding that research.
        Amendments: This section amends current law by (1)
    eliminating the specific set-aside of $200,000 for research and
    replacing it with general authority to fund research for Indian
    health programs, instead of only the IHS; (2) requiring the
    Secretary to coordinate, to the extent practical, the resources
    and activities for Indian health research needs; (3)
    authorizing funding for both clinical and nonclinical research;
    and (4) providing for a periodic evaluation and dissemination
    of the research to Tribal Health Programs.
        Current Law: This section is Section 1621g of current law.

    Section 207. Mammography and other cancer screening

        This section requires the Secretary to provide for
    mammography and other cancer screening, consistent with the
    screening recommendations of the United States Preventive
    Services Task Force.
        Amendments: This section amends current law by authorizing
    other cancer screening, and eliminating the minimum age
    requirement of 35 for Indian women and opening the mammography
    screening to all Indian women, at a frequency under appropriate
    national standards.
        Current Law: This section is Section 1621k of current law.

    Section 208. Patient travel costs

        Section 208 requires the Secretary to provide funds for the
    travel costs of patients and their qualified escorts,
    associated with receiving health care services. A definition of
    ``qualified escort'' for purposes of accompanying a patient who
    is traveling to receive health care services is provided.
        Amendments: This section maintains current law and adds
    language which allows the use of qualified escorts and
    transportation by private vehicle (where no other
    transportation is available), specially equipped vehicle,
    ambulance or by other means required when air or motor vehicle
    transport is not available.
        Current Law: This section is Section 1621l of current law.

    Section 209. Epidemiology centers

        This section directs the Secretary to establish an
    epidemiology center in each Service Area. The functions of
    these centers are delineated. The Director of the Centers for
    Disease Control and Prevention is required to provide technical
    assistance to the centers. The Secretary is also authorized to
    make grants to Tribes, Tribal Organizations, Urban Indian
    Organizations and eligible intertribal consortia to conduct
    epidemiological studies of Indian communities. Eligibility
    requirements for consortia, application requirements and use of
    grant funds are specified. This section also authorizes the
    Secretary to provide access to information in the possession of
    the Secretary to an epidemiology center operated by a grantee
    pursuant to a grant awarded under this section.
        Amendments: This section amends current law by (1)
    maintaining the centers in existence on the date of passage of
    this Act, but still requiring the establishment of centers in
    the remaining Areas; (2) allowing new centers to be operated
    under a grant under this section, but the funding under such a
    grant shall not be divisible; (3) eliminating the requirements
    in current law that the Secretary establish the data and
    formats for reporting and establish the system for monitoring
    progress toward the health objectives; and (4) providing that
    an epidemiology center operated under this section shall be
    treated as a public health authority for purposes of the Health
    Insurance Portability and Accountability Act of 1996 and
    directing the Secretary to grant grantees access to and use of
    data and other protected health information in the possession
    of the Secretary.
        Current Law: This section is Section 1621m of current law.

    Section 210. Comprehensive school health education programs

        Section 210 allows the Secretary to provide grants to
    Indian Tribes, Tribal Organizations and Urban Indian
    Organizations to develop comprehensive school health education
    programs for children from pre-school through grade 12 in
    schools for the benefit of Indian and Urban Indian children.
    The specific purposes for which grant funds may be used are
    delineated. Upon request, the Secretary shall provide technical
    assistance in the development and dissemination of
    comprehensive health education plans, materials and
    information. The Secretary, through the Service and in
    consultation with Tribes, Tribal Organizations and Urban Indian
    Organizations, shall establish criteria for review and approval
    of applications for this funding. For Bureau of Indian Affairs-
    funded schools, the Secretary of the Interior shall develop a
    similar school health education program.
        Amendments: This section maintains current law and adds
    language which (1) clarifies the types of purposes for which
    the funds may be used, such as for both regular school and
    after school programs, for the benefit of Indian and urban
    Indian children, for oral health programs, for violence
    prevention and for other health issues, as appropriate; (2)
    expands the grants to include Tribal Organizations and Urban
    Indian Health Organizations as eligible for funding, as well as
    Tribes; (3) deletes the reporting requirements of current law;
    and (4) requires that the application criteria be established
    in consultation with Indian Tribes, Tribal Organizations and
    Urban Indian Organizations.
        Current Law: This section is Section 1621n of current law.

    Section 211. Indian youth program

        This section authorizes the Secretary to establish and
    administer a program for innovative mental and physical disease
    prevention and health promotion and treatment for Indian and
    Urban Indian preadolescent and adolescent youths. Allowable and
    prohibited uses of the funds authorized by this section are
    delineated. The Secretary is required to disseminate
    information regarding models for delivery of comprehensive
    health care services to Indian youth; to encourage the
    implementation of these models; and to provide technical
    assistance upon request. The Secretary will establish criteria
    for review and approval of applications under this section in
    consultation with Tribes, Tribal Organizations and Urban Indian
    Organizations.
        Amendments: This section maintains current law and adds
    Tribal Organizations and Urban Indian Organizations as
    participants in the program and consultation, and includes
    urban Indian youth as beneficiaries of program services. The
    specific authorization of this program in current law is
    deleted.
        Current Law: This section is Section 1621o of current law.

    Section 212. Prevention, control, and elimination of communicable and
            infectious diseases

        Section 212 authorizes the Secretary to make grants
    available to projects specifically for the purpose of
    preventing, controlling and eliminating communicable and
    infectious diseases. Funding is also authorized for public
    information and education programs; education, training and
    clinical skills improvement activities for health
    professionals; and demonstration projects for the screening,
    treatment and prevention of the hepatitis C virus. Funding
    under this section requires an application or proposal to be
    submitted. Entities which receive funding under this section
    are encouraged to coordinate their activities with the Centers
    for Disease Control and Prevention, as well as with state and
    local health agencies. Finally, in carrying out this section,
    the Secretary may provide technical assistance, upon request,
    and shall submit a biennial report to Congress on the use of
    the funds and the progress made toward prevention, control, and
    elimination of communicable and infectious diseases among
    Indians and Urban Indians.
        Amendments: This section amends current law by (1)
    including Urban Indian Organizations; (2) expanding the
    communicable diseases from simply tuberculosis to other
    communicable and infectious diseases; (3) by encouraging,
    rather than requiring, that entities funded under this section
    coordinate with the Centers for Disease Control and state and
    local health agencies; and (4) by eliminating provisions of
    current law which would reduce the grant amount for expenses
    incurred by the federal government or for supplies or equipment
    furnished to the grant recipient.
        Current Law: This section is Section 1621q of current law.

    Section 213. Other authority for provision of services

        This section authorizes the Secretary to fund other
    activities which meet the objectives set forth in Section 3 of
    this Act through health care-related services and programs not
    otherwise described in the Act, including hospice care,
    assisted living, long-term health care, and home- and
    community-based services. Services are to be in provided in
    accordance with accepted and appropriate standards relating to
    the service, including any licensing term or condition. The
    Secretary is authorized to establish standards, by regulation,
    for a service provided under this section, provided that those
    standards are not more stringent than the standards required by
    the state in which the service is provided. If the Secretary
    does not establish standards by regulation, state standards
    shall apply. If a service under this section is provided by an
    Indian Tribe or Tribal Organization pursuant to the Indian
    Self-Determination and Education Assistance Act, the
    verification by the Secretary that the service meets any
    standards required by the state in which the service is or will
    be provided shall be considered to meet the terms and
    conditions required. The individuals who are eligible to
    receive long-term care under this section are specified, and
    the terms ``home- and community-based services'' and ``hospice
    care'' are defined. This section also authorizes the Secretary
    to provide funding to meet the objectives set forth in Section
    3 of this Act for convenient care services programs pursuant to
    section 306(c)(2)(A).
        Amendments: This section amends current law by making
    permanent a demonstration project for home- and community-based
    care. New provisions also (1) add standards; (2) add several
    definitions and deletes the definition of ``functionally
    disabled'' found in current law; and (3) eliminates the
    exclusion of cash payments, room and board, construction and
    nursing facility services. The provision authorizing the
    Secretary to provide funding to meet the objectives set forth
    in Section 3 of this Act for convenient care services programs
    is new.
        Current Law: Section 1680k authorizes the Secretary to
    establish not more than 24 demonstration projects for home-and
    community-based care (excluding cash payments, room and board,
    construction and nursing facility services), for functionally
    disabled Indians. Discretion is provided to the Indian Health
    Service, Indian Tribes, or Tribal Organizations to provide such
    care to persons otherwise ineligible for the health care
    benefits of the Indian Health Service (on a cost basis). The
    Secretary is required to submit to the President for inclusion
    in a report to Congress the findings of these projects. ``Home-
    and community-based services'' and ``functionally disabled''
    are defined.

    Section 214. Indian women's health care

        This section requires the Secretary, acting through the
    Service, Indian Tribes, Tribal Organizations and Urban Indian
    Organizations, to monitor and improve health care for Indian
    women of all ages through the planning and delivery of programs
    administered by the Service.
        Amendments: This section amends current law by eliminating
    the Office of Indian Women's Health and, instead, requiring the
    Secretary to monitor and improve the quality of Indian women's
    health through the various programs administered by IHS.
        Current Law: Section 1621v establishes an Office of Indian
    Women's Health Care to oversee efforts of the IHS to monitor
    and improve health care for Indian women of all ages.

    Section 215. Environmental and nuclear health hazards

        Section 215 requires the Secretary, in conjunction with
    other Federal agencies and in consultation with concerned
    Tribes and Tribal Organizations, to conduct studies and ongoing
    monitoring programs to determine trends in the health hazards
    to Indian miners and other Indians as a result of environmental
    hazards, such as nuclear resource development, petroleum
    contamination, and contamination of water sources and the food
    chain. Upon completion of such studies, the Secretary shall
    develop health care plans to address these health problems. The
    Secretary is required to submit the study to Congress 18 months
    after the date of enactment and a report no later than 1 year
    after the study which shall include recommendations for the
    implementation of the health care plan and evaluation
    activities. This section establishes an Intergovernmental Task
    Force to identify environmental hazards and to take corrective
    action. The Secretary is to chair this Task Force, which shall
    meet at least twice yearly. If an Indian who is employed in or
    around any environmental hazard suffers from a work-related
    condition, the Indian Health Program which treats him may be
    reimbursed by the Indian's employer.
        Amendments: This section maintains current law and adds
    language which (1) requires ongoing monitoring of trends in
    health hazards to Indians and other environmental hazards to
    Indian communities; and (2) provides additional elements of the
    studies conducted under this section.
        Current Law: This section is Section 1677 of current law.

    Section 216. Arizona as a contract health service delivery area

        This section designates the State of Arizona as a contract
    health service delivery area for providing contract health care
    services to members of federally recognized Indian Tribes of
    Arizona. The Indian Health Service is not to curtail any
    services as a result of this provision.
        Amendments: This section maintains current law and extends
    the date to 2017, instead of 2000, for the designation as a
    contract health service delivery area.
        Current Law: This section is Section 1678 of current law.

    Section 216A. North Dakota and South Dakota as contract health service
            delivery area

        This section designates the States of North Dakota and
    South Dakota as one contract health service delivery area for
    providing contract health care services to members of federally
    recognized Indian Tribes in North and South Dakota. The Indian
    Health Service is not to curtail any services as a result of
    this provision.
        Amendments: This section is new to the Act and is not
    contained in current law.

    Section 217. California contract health services program

        This section authorizes the Secretary to fund a program
    using the California Rural Indian Health Board (CRIHB) as a
    contract care intermediary to improve the accessibility of
    health services to California Indians. The Secretary will
    reimburse the CRIHB for costs incurred pursuant to this
    section. Not more than 5 percent of the amounts provided under
    this section to the CRIHB in any fiscal year may be for
    administrative expenses. No payment may be made for treatment
    under this section to the extent payment may be made under the
    Indian Catastrophic Health Emergency Fund or from amounts
    appropriated or otherwise made available to the California
    contract health service delivery area. This section also
    establishes an Advisory Board to advise the CRIHB in carrying
    out this section. The Advisory Board shall be comprised of
    representatives from not less than 8 Tribal Health Programs
    serving California Indians covered under this section, and at
    least one-half of whom are not affiliated with the CRIHB.
        Amendments: This section amends current law by turning the
    demonstration project for the California Indians into a
    permanent program.
        Current Law: This section is Section 1621j of current law.

    Section 218. California as a contract health service delivery area

        This section designates the State of California, excluding
    certain specified counties, as a contract health service
    delivery area for the purpose of providing contract health care
    services to California Indians. The excluded counties may be
    included only if funding is specifically provided by the Indian
    Health Service for such services in those counties.
        Amendments: This section maintains current law, but allows
    the excluded counties to become a part of the contract service
    delivery area if funding is specifically provided for such
    services in those counties.
        Current Law: This section is Section 1680 of current law.

    Section 219. Contract health services for the Trenton service area

        This section directs the Secretary to provide contract
    health services to members of the Turtle Mountain Band of
    Chippewa Indians who reside in the Trenton Service Area of
    Divide, McKenzie, and Williams counties in North Dakota and the
    counties of Richland, Roosevelt, and Sheridan in Montana.
    Nothing in this section is to be construed as expanding the
    eligibility of members of the Turtle Mountain Band of Chippewa
    Indians for health services provided by the Service beyond the
    scope of eligibility for these services that applied on May 1,
    1986.
        Amendments: This section maintains current law.
        Current Law: This section is Section 1680e of current law.

    Section 220. Programs operated by Indian tribes and tribal
            organizations

        This section requires the Indian Health Service to provide
    funds to Tribal Health Programs for health care programs and
    facilities on the same basis as funds are provided to these
    programs operated directly by the Indian Health Service.
        Amendments: This section maintains current law, but
    eliminates language which specifies the particular use of funds
    for which the Indian Tribes and Tribal Organizations can
    receive funding on the same basis as the IHS.
        Current Law: Section 1680a requires the Indian Health
    Service to provide funds to tribes and tribal organizations
    health care programs and facilities to (1) maintain and repair
    clinics, (2) train employees, (3) provide cost-of-living
    expenses, and (4) provide for other expenses related to health
    services on the same basis as funds are provided to these
    programs operated directly by the Indian Health Service.

    Section 221. Licensing

        Section 221 requires that health care professionals
    employed by a Tribal Health Program shall, if licensed in any
    State, be exempt from the licensing requirements of the State
    in which the Tribal Health Program provides the services.
        Amendments: This section is new to the Act and is not
    contained in current law.

    Section 222. Notification of provision of emergency contract health
            services

        This section allows 30 days (as a condition of payment) for
    an elderly or disabled Indian to notify the Service of any
    emergency medical care or services received from a non-Service
    provider or in a non-Service facility.
        Amendments: This section maintains current law.
        Current Law: This section is Section 1646 of current law.

    Section 223. Prompt action on payment of claims

        Section 223 provides a deadline for the Service to respond
    to notification of a claim by a provider of a contract care
    service. The section also provides that if the Service fails to
    respond within the required time, the Service shall accept the
    claim submitted by the provider as valid. The IHS shall pay a
    valid claim within 30 days after the completion of the claim.
        Amendments: This section maintains current law, but changes
    the requirement of a completed claim to a valid claim.
        Current Law: This section is Section 1621s of current law.

    Section 224. Liability for payment

        This section provides that a patient who receives
    authorized contract health care services will not be held
    liable for any charges or costs associated with those
    authorized services. The Secretary is required to notify the
    contract care provider and the patient who receives such
    services that the patient is not liable within a specified
    time. Following receipt of this notice or an acceptable claim
    under the previous section, the provider shall have no further
    recourse against the patient who received the health care.
        Amendments: This section maintains current law and adds
    language which limits the recourse against the patient if the
    claim has been deemed accepted under Section 223.
        Current Law: This section is Section 1621u of current law.

    Section 225. Office of Indian Men's Health

        This section provides that the Secretary may establish the
    Office of Indian Men's Health to coordinate and promote the
    health status of Indian men. The Office will be headed by a
    director, who is to be appointed by the Secretary. The
    Secretary is also required to submit a report to Congress
    within two years of enactment, describing any activity and
    finding about the health of Indian men of the director.
        Amendments: This section is new to the Act and is not
    contained in current law.

    Section 226. Authorization of appropriations

        This section authorizes to be appropriated such sums as may
    be necessary to carry out this title for each fiscal year
    through fiscal year 2017.
        Amendments: This section maintains current law, but extends
    the authorization from fiscal year 2000 to fiscal year 2017 and
    eliminates the references to specific sections which had a
    separate authorization period.
        Current Law: This section is Section 1621w of current law.

                             TITLE III--FACILITIES

    Section 301. Consultation; Construction and renovation of facilities;
            Reports

        This section requires that prior to expending construction
    funds, the Secretary shall consult with impacted Indian Tribes,
    and ensure that facilities built pursuant to this section meet
    certain construction standards within one year after the date
    on which the construction or renovation of such facility is
    completed. In addition, Section 301 sets forth requirements to
    be met prior to closing any facility.
        This section also directs the Secretary to maintain a
    health care facility priority system which shall be developed
    in consultation with Indian Tribes and Tribal Organizations and
    meet other requirements. The priority of any project
    established under the construction priority system in effect on
    the date of enactment, if the project meets certain criteria,
    is protected. Not later than 1 year after the date of enactment
    of the Indian Health Care Improvement Act Amendments of 2007,
    the Secretary shall submit to Congress a report that describes
    the comprehensive, national, ranked list of all health care
    facilities needs for the Service, Indian Tribes, and Tribal
    Organizations. Beginning in calendar year 2011, the Secretary
    shall update this report not less frequently than once every 5
    years. Annual reports are also required under this section.
        Not later than 1 year after the establishment of the health
    care facilities construction priority system under this
    section, the Comptroller General of the United States shall
    prepare and finalize a report to Congress, that reviews the
    methodologies applied, and the processes followed, by the
    Service in making each assessment of needs for the priority
    system. This section also directs the Secretary to consult and
    cooperate with Indian Tribes, Tribal Organizations, and Urban
    Indian Organizations in developing innovative approaches to
    address all or part of the total unmet need for construction of
    health facilities.
        Amendments: This section maintains current law and builds
    on it substantially. Language is added which (1) requires an
    evaluation of the impact of a proposed closure prior to
    closing; (2) requires the Secretary to maintain a health care
    facility priority system developed through consultation, which
    prioritizes certain facilities; (3) adds specific requirements
    for the initial, comprehensive report to Congress and
    subsequent annual reports; (4) requires the Secretary to
    consult and cooperate with Indian Tribes, Tribal Organizations,
    and Urban Indian Organizations in developing innovative
    approaches to meet facilities needs; and (5) requires the
    Comptroller General to prepare a report to Congress which
    reviews the methodology used for the health facilities
    construction priority list.
        Current Law: This section is Section 1631 of current law.

    Section 302. Sanitation facilities

        This section provides findings, certain responsibilities of
    the Service for sanitation, authorized uses of sanitation
    funding and facilities, and reporting requirements, and
    establishes the deficiency levels for those facilities. This
    section requires training or technical assistance in the
    operation and maintenance of sanitation facilities, and
    priority funding for operation and maintenance or emergency
    repairs.
        Section 302 authorizes the Secretary to accept funds from
    any source, including funds appropriated under the Native
    American Housing Assistance and Self-Determination Act, for
    construction of sanitation facilities. The Secretary, after
    consulting with the Secretary of Housing and Urban Development
    and Indian Tribes, Tribal Organizations and tribally designated
    housing entities, is also required to submit a report to
    Congress on the sanitation facilities priority system and a 10-
    year plan to provide sanitation facilities to new and renovated
    Indian homes. Deficiency levels for sanitation facilities are
    defined.
        Amendments: This section maintains current law and adds
    language which (1) establishes priority funding for emergency
    repairs and operation or maintenance to avoid imminent health
    threats or to protect the investment in health benefits gained
    through the sanitation facilities; (2) prohibits the use of IHS
    funding to provide sanitation facilities to new homes
    constructed using Department of Housing and Urban Development
    funds; (3) allows the Secretary to accept funds from any
    source, including federal and state agencies, for sanitation
    facilities and services, and to place those funds into
    contracts or compacts under the Indian Self-Determination and
    Education Assistance Act; (4) authorizes the Secretary to allow
    certain funding to be used to fund tribal loans or matching or
    cost participation requirements to construct sanitation
    facilities; (5) requires the Secretary enter into interagency
    agreements for financial assistance; (6) requires consultation
    in preparation of the report to Congress, and clarifies the
    information required to be in the annual report; and (7)
    establishes an Indian Tribe's primary responsibility for
    collecting user fees and the Secretary's responsibility in
    assisting tribes when the facility is threatened with imminent
    failure.
        Current Law: This section is Section 1632 of current law.

    Section 303. Preference to Indians and Indian firms

        This section authorizes the Secretary to give preference to
    Indians or Indian or tribal enterprises or other businesses in
    the construction and renovation of Service facilities pursuant
    to section 301, and in the construction of sanitation
    facilities pursuant to section 302. Compliance with certain
    labor standards is required.
        Amendments: This section maintains current law and adds new
    language to clarify rates of pay requirements and other wage
    requirements similar to local rates as determined by the Indian
    tribes or Tribal Organizations to be served by the
    construction.
        Current Law: This section is Section 1633 of current law.

    Section 304. Expenditure of non-service funds for renovation

        This section authorizes the Secretary to accept any
    expansion, renovation or modernization of any Service or tribal
    health facility funded with non-Service funds in accordance
    with certain criteria. The Secretary is required to maintain a
    separate priority list for these facilities, which shall be
    submitted to Congress as part of the annual report to Congress.
    Indian Tribes or Tribal Organizations are required to meet
    certain requirements for expansions, renovations or
    modernizations. This section also provides that if any Service
    facility which has been expanded, renovated, or modernized
    under this section ceases to be used as a Service facility
    during the 20-year period beginning on the date such expansion,
    renovation, or modernization is completed, such Indian Tribe or
    Tribal Organization shall be entitled to recover from the
    United States an amount which bears the same ratio to the value
    of such facility at the time of such cessation as the value of
    such expansion, renovation, or modernization bore to the value
    of such facility at the time of the completion of such
    expansion, renovation, or modernization.
        Amendments: This section maintains current law and adds
    language which (1) includes major expansion as an authorized
    use of funds, in addition to renovation and modernization, but
    requires the Indian Tribes or Tribal Organizations to provide
    certain information to the Secretary regarding staffing,
    equipment and other costs associated with the expansion; and
    (2) requires the methodology for determining priorities to be
    developed through regulations.
        Current Law: This section is Section 1634 of current law.

    Section 305. Funding for the construction, expansion and modernization
            of small ambulatory care facilities

        This section authorizes the Secretary to make grants to
    Indian Tribes and Tribal Organizations for the construction,
    expansion, or modernization of facilities for the provision of
    ambulatory care services. Use of funds, grant application
    requirements, priorities, and conditions for reversion of
    facilities are set forth.
        Amendments: This section maintains current law and adds
    language which (1) requires the funding to be used for the
    portion of costs which benefits the eligible population, but
    exempts from the specific eligibility requirements applicants
    whose principal health administration offices are located where
    there is no road system providing direct access to inpatient
    hospitals; (2) adds additional capacity requirements for a
    facility constructed with a grant under this section; (3) makes
    reduction of an outstanding debt for construction, expansion or
    modernization an additional allowable use of funds; and (4)
    authorizes peer review panels to be established to evaluate
    applications and proposals.
        Current Law: This section is Section 1636 of current law.

    Section 306. Indian health care delivery demonstration projects

        This section authorizes the Secretary to establish a health
    care delivery demonstration project to test alternative means
    of delivering health care and services to Indians through
    facilities. There would be two kinds of demonstration projects.
    General projects would be authorized, with priority given to
    projects located in specific Service Areas, if they meet the
    specified criteria, such as the need for such facility, number
    of Indians to be served, the economic viability of the project,
    and the administrative and financial capability of Indian
    Tribes or Tribal Organizations to administer the project.
    Health care delivery demonstration projects would also be
    authorized that include a convenient care services program as
    an alternative means of delivering health care services to
    Indians. This section also requires technical assistance and
    use of the same criteria in evaluating tribal and IHS
    facilities.
        Amendments: This section maintains current law and adds
    language which (1) permits the use of IHS funds to match other
    funds; (2) authorizes the convenient care services
    demonstration projects; and (3) authorizes peer review panels
    to be established to review and evaluate applications. Language
    of current law authorizing reports to Congress on the findings
    and conclusions of the demonstration projects has been deleted.
        Current Law: This section is Section 1637 of current law.

    Section 307. Land transfer

        This section authorizes the Secretary to accept any land
    and improvements transferred, at no cost, from the Bureau of
    Indian Affairs or other federal agencies for the provision of
    health care services.
        Amendments: This section amends current law by changing a
    specific authorization into a general authorization whereby
    federal agencies may transfer land and improvements to the IHS
    for the provision of health care services.
        Current Law: Section 1638 provides specific authorization
    for transferring 5 acres of land at the Chemawa Indian School
    in Salem, OR, to the IHS.

    Section 308. Leases, contracts and other agreements

        This section authorizes the Secretary to enter into leases,
    contracts and other agreements with Indian Tribes and Tribal
    Organizations which have facilities for the delivery of health
    services at those facilities. The agreements may also include
    provisions for construction, renovation and compensation.
        Amendments: This section essentially maintains current law.
    The provision of current law authorizing the Secretary to enter
    into 20-year leases with Tribes that may specify reconstruction
    or renovation of property has been deleted.
        Current Law: This section is Section 1674 of current law.

    Section 309. Study for loans, loan guarantees and loan repayment

        This section directs the Secretary to conduct a study to
    determine the feasibility of establishing a loan fund to
    provide Indian Tribes and Tribal Organizations direct loans or
    loan guarantees for health care facilities construction. A
    number of study requirements are delineated. The results of the
    study shall be reported to Congress.
        Amendments: This section is new and is not now contained in
    current law.

    Section 310. Tribal leasing

        This section authorizes a tribal health program to lease
    permanent structures for the purpose of providing health care
    services without obtaining prior approval in appropriation
    Acts.
        Amendments: This section maintains current law, and expands
    the program to include Tribal Organizations.
        Current Law: This section is Section 1680j of current law.

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

        This section authorizes the Secretary to make arrangements
    with Indian Tribes and Tribal Organizations to establish joint
    venture demonstration projects, under which an Indian Tribe or
    Tribal Organization would expend tribal, private, or other
    available funds for the acquisition or construction of a health
    facility for a minimum of 10 years, under a no-cost lease. In
    exchange, the Service will agree to provide the equipment,
    supplies, and staffing for the operation and maintenance of
    such a health facility. Certain capabilities and other
    requirements are set forth. There are provisions for breach of
    agreement by either the Tribe or Tribal Organization or the
    IHS.
        Amendments: This section maintains current law and adds (1)
    Tribal Organizations to the eligible participants and those
    Tribes that have begun, but not completed the process of
    acquisition or construction of a health care facility; (2)
    requires negotiation for the continued operation of the
    facility at the end of the 10-year lease; (3) authorizes
    recovery in a proportional amount from the IHS if the IHS
    ceases to use the facility within the 10-year lease period; and
    (4) includes staff quarters in the definition of the health
    facilities under this section.
        Current Law: This section is Section 1680h(e) of current
    law.

    Section 312. Location of facilities

        This section directs the Bureau of Indian Affairs and the
    Service to give priority to locating health care facilities and
    employment projects in economically depressed areas to Indian
    and Alaska Native lands, if requested by the Indian owner and
    Indian Tribe with jurisdiction over such lands.
        Amendments: This section maintains current law and adds
    language to (1) include lands in Alaska owned by any Alaska
    Native village, or village or regional corporation under the
    Alaska Native Claims Settlement Act, or any land allotted to
    any Alaska Native; and (2) gives top priority to Indian land
    owned by 1 or more Indian Tribes. The definition of ``Indian
    lands'' is modified from current law.
        Current Law: This section is Section 1680n of current law.

    Section 313. Maintenance and improvement of health care facilities

        This section requires the Secretary to report to Congress
    on the backlog of maintenance and repair work required at both
    Service and tribal health care facilities. This section also
    authorizes an Indian Tribe or Tribal Organization to use
    maintenance and improvement funds for construction of a
    replacement facility, as well as for renovation, modernization,
    and expansion of facilities, under certain circumstances.
        Amendments: This section is new and is not now contained in
    current law.

    Section 314. Tribal management of federally-owned quarters

        This section authorizes Tribal Health Programs operating a
    health care facility and federally-owned quarters pursuant to a
    contract or compact under the Indian Self-Determination and
    Education Assistance Act to establish reasonable rental rates
    for the federally-owned quarters, and to collect the rent
    directly from federal employees who occupy such quarters. These
    quarters shall remain eligible for improvement and repair funds
    as other federally-owned quarters. The Tribal Health Program
    operating the quarters is required to provide at least 60 days
    notice before changing the rental rate.
        Amendments: This section is new and is not now contained in
    current law.

    Section 315. Applicability of Buy American Act requirement

        This section requires application of the Buy American Act
    for all procurements under this title. Indian Tribes and Tribal
    Organizations are exempt from this requirement.
        Amendments: This section maintains current law, but exempts
    Indian Tribes and Tribal Organizations from the requirements of
    the Buy American Act, and eliminates the reporting requirement
    contained in current law.
        Current Law: This section is Section 1638b of current law.

    Section 316. Other funding for facilities

        This section authorizes the Secretary to accept funds from
    other sources for the construction of health care facilities
    and to place such funds into a contract or compact under the
    Indian Self-Determination and Education Assistance Act. The
    Secretary is also authorized to enter into interagency
    agreements with other federal or state agencies for the
    planning, design and construction of health care facilities to
    be administered by Indian Health Programs.
        Amendments: This section is new and is not now contained in
    current law.

    Section 317. Authorization of appropriations

        This section authorizes to be appropriated such sums as may
    be necessary for each fiscal year through fiscal year 2017 to
    carry out this title.
        Amendments: This section maintains current law but extends
    the authorization for appropriations beyond fiscal year 2000
    through fiscal year 2017.
        Current Law: This section is Section 1638a of current law.

                      TITLE IV--ACCESS TO HEALTH SERVICES

    Section 401. Treatment of payments under Social Security Act health
            care benefits programs

        This section requires that any Medicare, Medicaid, or State
    Children's Health Insurance Program (SCHIP) payments received
    by an Indian Health Program or Urban Indian Organization for
    services provided to eligible Indians shall not be considered
    in determining appropriations for the provision of health care
    and services. Indians without Medicare, Medicaid or SCHIP
    coverage are to be given equal consideration as Indians who are
    covered by these Social Security Act health benefit programs.
    Payments to which a facility of the Service is entitled by
    reason of a provision of the Social Security Act are to be
    placed in a special fund to be held by the Secretary. In making
    payments from such fund, the Secretary is to ensure that each
    Service Unit receives 100% of the amount to which the facility
    of the Service, for which such Service Unit makes collections,
    is entitled. How funds collected from Medicare, Medicaid, or
    SCHIP are to be used is specified. This section also allows
    Tribal Health Programs to elect to directly bill for, and
    receive payment for, health care items and services provided by
    that Tribal Health Program for which payment is made under
    Medicare, Medicaid, SCHIP, or third party payors.
        Amendments: This section maintains current law and (1) adds
    Tribal Organizations and Urban Indian Organizations, in
    addition to Tribes and the IHS, for whom reimbursements would
    not be considered in determining appropriations; (2) authorizes
    the 100% pass-through of payments due to Service facilities
    from the special fund; and (3) expands the authorized uses of
    the reimbursements from improvements only to hospitals or
    skilled facilities to also include programs and the excess used
    to reduce health deficiencies, subject to consultation by the
    Indian Tribes served. However, this provision authorizing the
    Secretary to determine the uses shall not apply when the Indian
    Tribes elect to receive reimbursements directly.
        Current Law: Sections 1641 and 1642 address treatment of
    payments under Medicare or Medicaid. Section 1645 established a
    program under which tribes could elect to directly bill and be
    reimbursed for health care services provided under Medicare,
    Medicaid or other third parties.

    Section 402. Grants to and contracts with the service, Indian tribes,
            tribal organizations, and urban Indian organizations to
            facilitate outreach, enrollment, and coverage of Indians under
            Social Security Act health benefit programs and other health
            benefits programs

        This section directs the Secretary to make grants to or
    enter into contracts with Tribes and Tribal Organizations to
    improve enrollment and participation in Medicare, Medicaid or
    SCHIP programs, including paying premiums or cost sharing
    (which terms are defined in this section). In doing so, the
    Secretary shall place such conditions as are deemed necessary
    to affect the purpose of this section, including certain
    requirements of the Indian Tribe or Tribal Organization.
    Specifications for applying this section to Urban Indian
    Organizations are included. This section also directs the
    Secretary, acting through the Centers for Medicare and Medicaid
    Services, to take such steps as are necessary to facilitate
    cooperation with, and agreements between, States and the
    Service, Indian Tribes, Tribal Organizations, or Urban Indian
    Organizations with respect to the provision of health care
    items and services to Indians and to improving the enrollment
    of Indians under Social Security Act health benefits programs.
    This section also provides a cross-reference to the relevant
    section of the Social Security Act for provisions related to
    agreements between the Secretary and Indian Tribes, Tribal
    Organizations, and Urban Indian Organizations for the
    collection, preparation, and submission of applications by
    Indians for assistance under Medicare, Medicaid and SCHIP.
        Amendments: This section maintains current law and adds
    provisions which outline the agreements between the Secretary
    and the Tribes, Tribal or Urban Indian Organizations to improve
    the enrollment of Indians in Social Security Act programs.
        Current Law: This section is Section 1644 of current law.

    Section 403. Reimbursement from certain third parties of costs of
            health services

        Section 403 provides that the United States, an Indian
    Tribe, or Tribal Organization has the right to recover from an
    insurance company, health maintenance organization, employee
    benefit plan, or any third party the reasonable charges billed
    by the Secretary, an Indian Tribe, or Tribal Organization in
    providing health services to any individual to the same extent
    that such individual, or any nongovernmental provider of such
    services, would be eligible to receive damages, reimbursement,
    or indemnification. This right of recovery is extended against
    any state, under certain conditions. Certain state or local
    laws are deemed nonapplicable to prevent or hinder this right
    of recovery. This section has no effect on private rights of
    action. Enforcement measures for the right of recovery, notice,
    costs and attorneys' fees are all specified in this section.
    Section 403 limits the Indian Health Service right of recovery
    against a tribal self-insured plan absent written consent from
    the Tribe. Other items covered in this section include
    nonapplication of claims filing requirements; application to
    Urban Indian Organizations; statute of limitations; and a
    savings clause.
        This section adds a new provision which would extend to
    Tribes and Tribal Organizations the same authority the U.S. has
    under the Federal Medical Care Recovery Act (FMCRA) to recover
    the costs of medical care from a tortfeasor whose action caused
    an injury or disease to a patient whom a federal health care
    provider is obliged to treat. While the Department of Justice
    brings such suits against tortfeasors for federal health care
    providers such as the IHS, it does not currently do so for
    Tribes which operate IHS-funded health programs.
        Amendments: This section maintains current law and adds
    language (1) to enable Urban Indian Organizations to seek
    recovery from third parties; (2) to require reasonable efforts
    be taken to provide notice to the patient either before or
    during the pendency of the action; (3) to limit the IHS right
    of recovery against a tribal self-insured plan absent written
    consent; (4) to include awards of reasonable attorneys' fees
    and costs of litigation; (5) to prohibit denial of
    reimbursement on the basis of a different format or form; and
    (6) to extend to Tribes and Tribal Organizations the same
    authority the U.S. has under the Federal Medical Care Recovery
    Act (FMCRA) to recover the costs of medical care from a
    tortfeasor.
        Current Law: This section is Section 1621e of current law.

    Section 404. Crediting of reimbursements

        This section authorizes the retention of the reimbursements
    received or recovered under this Act, Medicare, Medicaid or
    SCHIP and other provisions of law, from third parties and
    specifies the use of those reimbursements. This section also
    disallows any offset or limitation of amount obligated to any
    Service Unit, Indian Tribe or Tribal or Urban Indian
    Organization because of the receipt of reimbursements under
    this section.
        Amendments: This section maintains current law and adds
    language which specifies which programs are included in the
    reimbursements.
        Current Law: This section is Section 1621f of current law.

    Section 405. Purchasing health care coverage

        Section 405 allows Tribes, Tribal Organizations and Urban
    Indian Organizations to use funding for health benefits for
    Indians to be used to purchase health benefits coverage for
    Service beneficiaries in any manner (including through a
    tribally owned and operated health care plan, a state or
    locally authorized or licensed health care plan, a health
    insurance provider or managed care organization, or a self-
    insured plan), based on the financial needs of such
    beneficiaries.
        Amendments: This section replaces a provision of current
    law which authorized a managed care feasibility study.
        Current Law: Section 1621i of current law authorized the
    Secretary to conduct a study to assess the feasibility of
    allowing an Indian Tribe to purchase managed care coverage for
    tribal members from a tribally owned and operated managed care
    plan or a state or licensed managed care plan.

    Section 406. Sharing arrangements with Federal agencies

        This section allows the Secretary to enter into or expand
    arrangements to share medical facilities and services with the
    Departments of Veterans Affairs and Defense, with certain
    limitations. If health care services are provided to
    beneficiaries eligible for services from either the Department
    of Veterans Affairs or the Department of Defense, then the
    Service, Indian Tribe, or Tribal Organization providing the
    service shall be reimbursed from the appropriate Department.
    The Secretary shall not take action which would impair priority
    access to or quality of care for Indians at IHS or priority of
    veterans to care by the VA.
        Amendments: This section amends current law by (1)
    authorizing the Secretary to enter agreements for sharing of
    medical facilities with the Departments of Veterans Affairs
    (VA) and Defense, instead of merely examining the feasibility
    of entering agreements with the VA; (2) requiring consultation
    with the affected Indian Tribes prior to entering the
    agreements; (3) requiring reimbursement to the IHS, Tribes, or
    Tribal Organizations; and (4) eliminating the specific cross-
    utilization of services in Utah only (expanding it, generally).
        Current Law: Section 1680f of current law authorizes the
    Secretary to examine the feasibility of entering agreements to
    share medical facilities and services with the Department of
    Veterans Affairs, with a specific agreement for Utah.

    Section 407. Payor of last resort

        This section specifies that Indian Health Programs and
    health care programs operated by Urban Indian Organizations
    shall be the payor of last resort for services provided to
    eligible persons.
        Amendments: This section is new and is not contained in
    current law.

    Section 408. Nondiscrimination under Federal health care programs in
            qualifications for reimbursement for services

        Section 408 provides that a federal health care program
    must accept an entity that is operated by the 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. This section also provides that state or local
    licensure or recognition requirements by a provider of health
    care services shall be deemed to have been met in the case of
    an entity operated by the 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. Certain entities
    operated by the Service, an Indian Tribe, Tribal Organization,
    or Urban Indian Organization, or individuals who have 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 or individual is located, shall
    not be eligible to receive payment or reimbursement under any
    such program for health care services furnished to an Indian.
        Amendments: This section is new and is not contained in
    current law.

    Section 409. Consultation

        This section provides a cross-reference to the relevant
    section of the Social Security Act for provisions related to
    consultation with representatives of Indian Health Programs and
    Urban Indian Organizations with respect to the health care
    programs established under Medicare, Medicaid and SCHIP.
        Amendments: This section is new and is not contained in
    current law.

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

        This section provides cross-references to relevant sections
    of the Social Security Act for provisions relating to outreach
    to families of Indian children likely to be eligible for child
    health assistance under SCHIP, and ensuring that child health
    assistance is provided under such program to targeted low-
    income children who are Indians and that payments are made
    under that program.
        Amendments: This section is new and is not contained in
    current law.

    Section 411. Exclusion waiver authority for affected Indian health
            programs and safe harbor transactions under the Social Security
            Act

        This section provides cross-references to relevant sections
    of the Social Security Act for provisions relating to exclusion
    waiver authority for affected Indian Health Programs, and
    certain transactions involving Indian Health Programs deemed to
    be in safe harbors under the Social Security Act.
        Amendments: This section is new and is not contained in
    current law.

    Section 412. Premium and cost sharing protections and eligibility
            determinations under Medicaid and SCHIP and protection of
            certain Indian property from Medicaid estate recovery

        This section provides cross-references to relevant sections
    of the Social Security Act for provisions relating to premiums
    or cost sharing protections for Indians furnished items or
    services directly by Indian Health Programs or through referral
    under the contract health service under Medicaid; rules
    regarding the treatment of certain property for purposes of
    determining eligibility under Social Security Act programs; and
    the protection of certain property from estate recovery
    provisions under Medicaid.
        Amendments: This section is new and is not contained in
    current law.

    Section 413. Treatment under Medicaid and SCHIP managed care

        Section 413 provides cross-references to relevant sections
    of the Social Security Act for provisions relating to the
    treatment of Indians enrolled in a managed care entity under
    Medicaid, and Indian Health Programs and Urban Indian
    Organizations that are providers of items or services to such
    Indian enrollees.
        Amendments: This section is new and is not contained in
    current law.

    Section 414. Navajo Nation Medicaid Agency feasibility study

        Section 414 requires the Secretary to conduct a study to
    determine the feasibility of treating the Navajo Nation as a
    State for Medicaid purposes. Considerations for a report to
    Congress on the results of the study are described in this
    section.
        Amendments: This section is new and is not contained in
    current law.

    Section 415. General exceptions

        Section 415 provides that the requirements of this title
    shall not apply to any excepted benefits described in paragraph
    (1)(A) or (3) of section 2791(c) of the Public Health Service
    Act, which relates to supplemental insurance products.
        Amendments: This is a new provision and is not contained in
    current law.

    Section 416. Authorization of appropriations

        Section 416 authorizes to be appropriated such sums as may
    be necessary for each fiscal year through fiscal year 2017 to
    carry out this title.
        Amendments: This section extends the authorization beyond
    FY fiscal year 2000 to fiscal year 2017.
        Current Law: The authorization of appropriations section
    for the Access to Health Services title of current law is
    Section 1647, and extends through fiscal year 2000.

                   TITLE V--HEALTH SERVICES FOR URBAN INDIANS

    Section 501. Purpose

        This section sets forth the purpose of the title as
    establishing and maintaining programs in Urban Centers to make
    health services more accessible and available to Urban Indians.
        Amendments: This section maintains current law and adds
    language to maintain the programs and make health services
    available, in addition to being accessible, to Urban Indians.
        Current Law: This section is Section 1651 of current law.

    Section 502. Contracts with, and grants to, urban Indian organizations

        This section provides that the Secretary shall enter into
    contracts with, or make grants to, Urban Indian Organizations
    to assist such organizations in the establishment and
    administration, within Urban Centers, of programs which meet
    the requirements set forth in this title.
        Amendments: This section maintains current law.
        Current Law: This section is Section 1652 of current law.

    Section 503. Contracts and grants for the provision of health care and
            referral services

        This section sets forth the authority of the Secretary to
    enter into contracts with or make grants to Urban Indian
    Organizations to establish and administer programs under this
    title, which shall meet certain requirements. This section
    prescribes the criteria for selecting Urban Indian
    Organizations for contracts or grants. Such contracts or grants
    shall facilitate access to or provide services for health
    promotion and disease prevention, immunization services,
    behavioral health services, prevention of child abuse, and
    other services to Urban Indians.
        Amendments: This section maintains current law, generally,
    while (1) modifying contract and grant requirements and
    criteria; and (2) deleting factors to be considered for
    immunization services contracts or grants that are set forth in
    current law.
        Current Law: This section is Section 1653 of current law.

    Section 504. Contracts and grants for the determination of unmet health
            care needs

        This section authorizes the Secretary to enter into
    contracts with or make grants to Urban Indian Organizations for
    which contracts or grants have not been entered into under the
    prior section. The purpose of these contracts/grants would be
    to determine unmet health care needs of urban Indians. Grant
    and contract requirements are set forth.
        Amendments: This section maintains current law.
        Current Law: This section is Section 1654 of current law.

    Section 505. Evaluations; renewals

        This section authorizes the Secretary to develop evaluation
    and renewal procedures and standards for the various contracts
    and grants entered into by Urban Indian Organizations under
    this title, including considerations for renewals of contracts/
    grants. The Secretary shall also evaluate the urban Indian
    programs through onsite annual evaluations.
        Amendments: This section maintains current law and adds a
    provision which would allow the Secretary to evaluate the urban
    Indian organization through acceptance of evidence of the
    organization's accreditation as an alternative to the onsite
    annual evaluation.
        Current Law: This section is Section 1655 of current law.

    Section 506. Other contract and grant requirements

        This section sets forth other specific contract and grant
    requirements, such as payment methods, revisions and amendments
    to contracts, and assurance of the fair and uniform provision
    of services to Urban Indians.
        Amendments: This section maintains current law and adds
    provisions which (1) would allow a single advance payment,
    unless the urban Indian organization is not capable of
    administering the payments in their entirety and allows the
    funding to be carried forward; and (2) would allow payments to
    be made in semiannual or quarterly payments or by way of
    reimbursement. This section deletes provisions of current law
    allowing an Urban Indian Organization to use existing federal
    facilities.
        Current Law: This section is Section 1656 of current law.

    Section 507. Reports and records

        This section sets forth certain reporting and recordkeeping
    requirements for Urban Indian Organizations. This section also
    provides that not later than 18 months after the date of
    enactment, the Secretary, in consultation with Urban Indian
    Organizations, shall submit to Congress a report evaluating the
    health status of Urban Indians; the services provided to
    Indians pursuant to this title; and areas of unmet needs in the
    delivery of health services to Urban Indians. This section also
    provides that reports and records of the Urban Indian
    Organization shall be subject to audit by the Secretary and the
    Comptroller General of the United States.
        Amendments: This section maintains current law and (1) adds
    language which extends the reporting period to semi-annual,
    rather than quarterly; (2) adds the requirement of a minimum
    set of data using uniform elements; (3) adds that the audits
    may also be conducted by a certified public accounting firm;
    and (4) deletes the requirement that IHS and the Department of
    the Interior report to Congress by March 31, 1992, on the
    health status, unmet needs and welfare of urban Indian
    children.
        Current Law: This section is Section 1657 of current law.

    Section 508. Limitation on contract authority

        This section limits the authority of the Secretary to enter
    into contracts or to award grants under this title to the
    extent and amount provided for in appropriations Acts.
        Amendments: This section maintains current law and adds
    language which includes the Secretary's authority to award
    grants under this title.
        Current Law: This section is Section 1658 of current law.

    Section 509. Facilities

        This section provides that the Secretary, acting through
    the Service, may make grants for the lease, purchase,
    renovation, construction, or expansion of facilities. This
    section also allows the Secretary to carry out a study to
    determine the feasibility of establishing a loan fund to
    provide direct loans or guarantees for loans to Urban Indian
    Organizations for the construction of health care facilities.
        Amendments: This section replaces current law by adding
    provisions which would allow for leasing, purchasing,
    renovating, constructing and expanding, in addition to
    repairing, facilities. The provision regarding the feasibility
    study of a loan fund to construct facilities is new.
        Current Law: Section 1659 of current law authorizes the
    Secretary to make funds available to contractors or grant
    recipients to make minor renovations to the urban health
    facilities to meet or maintain compliance with the requirements
    of the Joint Commission on Accrediting Health Care
    Organizations.

    Section 510. Division of Urban Indian Health

        This section establishes a Division of Urban Indian Health
    within the Service to carry out the provisions of this title,
    provide oversight of the programs, and provide technical
    assistance to Urban Indian Organizations.
        Amendments: This section maintains current law, but (1)
    changes the Branch of Urban Indian programs into an Office
    within the IHS; (2) adds technical assistance; and (3) deletes
    provisions of current law regarding staffing, services and
    equipment.
        Current Law: This section is Section 1660 of current law.

    Section 511. Grants for alcohol and substance abuse-related services

        This section provides that the Secretary may make grants to
    Urban Indian Organizations for the provision of health-related
    services in prevention of, treatment of, rehabilitation of, or
    school- and community-based education regarding, alcohol and
    substance abuse in Urban Centers. Goals and criteria are set
    forth.
        Amendments: This section essentially maintains current law.
        Current Law: This section is Section 1660a of current law.

    Section 512. Treatment of certain demonstration projects

        This section makes permanent the Tulsa Clinic and Oklahoma
    City Clinic demonstration projects in Oklahoma and parallels
    the language of the Interior Appropriations Act which first
    contained this provision (Public Law 108-447).
        Amendments: This section maintains provisions which make
    permanent certain demonstration projects in Oklahoma, but
    modifies the language of current law of this Act to parallel
    the language of the Interior Appropriations Act which first
    contained this provision (Public Law 108-447).
        Current Law: This section is Section 1660b of current law.

    Section 513. Urban NIAAA transferred programs

        This section authorizes the Secretary, through the Division
    of Urban Indian Health, to make grants to or enter into
    contracts with Urban Indian Organizations, to take effect not
    later than September 30, 2010, for the administration of Urban
    Indian alcohol programs that were originally established under
    the National Institute on Alcoholism and Alcohol Abuse (NIAAA).
    Use of funds, eligibility and reporting requirements are set
    forth.
        Amendments: This section maintains current law, but (1)
    changes references to the Branch of Urban Indian Health to the
    Division; and (2) deletes the provision of current law allowing
    the Secretary to combine NIAAA alcohol funds with other
    substance abuse funds.
        Current Law: This section is Section 1660c of current law.

    Section 514. Consultation with urban Indian organizations

        This section provides that the Secretary shall ensure that
    the Service consults, to the greatest extent practicable, with
    Urban Indian Organizations, and defines ``consultation.''
        Amendments: This section is new and is not contained in
    current law.

    Section 515. Urban youth treatment center demonstration

        This section authorizes the Secretary to fund the
    construction and operation of at least 2 Indian youth
    residential treatment centers in certain states to demonstrate
    the provision of alcohol and substance abuse treatment services
    to Urban Indian youth in a culturally competent residential
    setting.
        Amendments: This section is new and is not contained in
    current law.

    Section 516. Grants for diabetes prevention, treatment, and control

        This section authorizes the Secretary to make grants to
    Urban Indian Organizations to provide services for the
    prevention and treatment of, and control of the complications
    resulting from, diabetes among Urban Indians, based on certain
    grant criteria that are set forth.
        Amendments: This section is new and is not contained in
    current law.

    Section 517. Community health representatives

        This section authorizes the Secretary to make grants to or
    enter into contracts with Urban Indian Organizations for the
    employment of Indians trained as health service providers
    through the Community Health Representatives Program.
        Amendments: This section is new and is not contained in
    current law.

    Section 518. Effective date

        This section establishes that the amendments made by the
    Act to this title shall take effect on the date of enactment,
    regardless of whether the Secretary has promulgated regulations
    implementing these amendments.
        Amendments: This section is new and is not contained in
    current law.

    Section 519. Eligibility for services

        This section provides that Urban Indians shall be eligible
    for, and the ultimate beneficiaries of, health care or referral
    services provided pursuant to this title.
        Amendments: This section is new and is not contained in
    current law.

    Section 520. Authorization of appropriations

        This section authorizes to be appropriated such sums as may
    be necessary for each fiscal year through fiscal year 2017 to
    carry out this title.
        Amendments: This section maintains current law and extends
    the authorization from fiscal year 2000 to fiscal year 2017.
        Current Law: This section is Section 1660d of current law.

                     TITLE VI--ORGANIZATIONAL IMPROVEMENTS

    Section 601. Establishment of the Indian Health Service as an agency of
            the Public Health Service

        This section establishes the Indian Health Service within
    the Public Health Service of the Department, and elevates the
    position of Director of the Indian Health Service to that of
    the Assistant Secretary for Indian Health. The Assistant
    Secretary for Indian Health shall be confirmed by the Senate
    with a term of four years, and shall administer the Indian
    Health Service. This section also specifies the duties and
    responsibilities of the Assistant Secretary and deems that any
    reference to the Director of the Indian Health Service in any
    Federal law, Executive order, rule, regulation, or delegation
    of authority, is deemed to refer to the Assistant Secretary.
        Amendments: This section amends current law to (1) change
    the position of the Director into an Assistant Secretary; (2)
    provide that the individual serving in the position of Director
    of the Service on the day before the date of enactment shall
    serve as Assistant Secretary; (3) provide that the position of
    Assistant Secretary is established to facilitate advocacy and
    promote consultation on matters relating to Indian health; (4)
    give the Assistant Secretary additional duties; and (5) deem
    current law or regulatory references to the Director to refer
    to the Assistant Secretary.
        Current Law: This section is Section 1661 of current law.

    Section 602. Automated management information system

        Section 602 requires the Secretary to establish automated
    management information systems for the Service and each Tribal
    Health Program which meets certain requirements. This section
    also requires that patients have access to their own health
    records, and authorizes the Secretary to enter in to contracts,
    agreements, or joint ventures with other federal agencies,
    states, private and nonprofit organizations for the purpose of
    enhancing information technology in Indian Health Programs and
    facilities.
        Amendments: This section maintains current law and adds
    Secretarial authority to enter contracts or joint ventures to
    enhance information technology in Indian health programs.
        Current Law: This section is Section 1662 of current law.

    Section 603. Authorization of appropriations

        This section authorizes to be appropriated such sums as may
    be necessary to carry out this title, for each fiscal year
    through fiscal year 2017.
        Amendments: This section maintains current law and extends
    the authorization from fiscal year 2000 to fiscal year 2017.
        Current Law: This section is Section 1663 of current law.

                     TITLE VII--BEHAVIORAL HEALTH PROGRAMS

    Section 701. Behavioral health prevention and treatment services

        Section 701 states the purposes of the section, including
    directing the Secretary, acting through the Service, Indian
    Tribes, Tribal Organizations, and Urban Indian Organizations,
    to develop a comprehensive behavioral health prevention and
    treatment program which emphasizes collaboration among alcohol
    and substance abuse, social services, and mental health
    programs. This section also requires the Secretary to encourage
    the development of plans for areawide Indian Behavioral Health
    Services; directs the Secretary to coordinate with existing
    national clearinghouses and information centers to include
    plans and reports of outcomes of such behavioral health plans
    developed by Indian Tribes, Tribal Organizations, Urban Indian
    Organizations, and Service Areas; directs the Secretary to
    provide comprehensive behavioral health care programs;
    facilitates the governing body of any Indian Tribe, Tribal
    Organization, or Urban Indian Organization to establish
    community behavioral health plans; requires the Secretary to
    coordinate behavioral health planning with other federal and
    state agencies; and directs the Secretary to assess the need,
    availability and cost for inpatient mental health care for
    Indians within 1 year.
        Amendments: This section maintains current law and adds
    language which (1) authorizes the Secretary, Indian Tribes,
    Tribal Organizations, and Urban Indian Organizations to develop
    programs which emphasize collaboration for behavioral health;
    (2) requires technical assistance to Indian Tribes, Tribal
    Organizations and Urban Indian Organizations; and (3) requires
    a continuum of care for behavioral health to the extent
    feasible, including acute hospitalization, detoxification, and
    emergency shelter.
        Current Law: This section is Section 1621h and Section 1665
    of current law.

    Section 702. Memoranda of agreement with the Department of the Interior

        This section requires the Secretary and the Secretary of
    the Interior to develop and enter, or review and update, within
    1 year, memoranda of agreement to, among other things, make a
    comprehensive assessment, coordination, and annual review of
    all the behavioral health care needs and services available or
    unavailable to Indians. Specific provisions that are required
    in this memorandum are delineated. Each memorandum of agreement
    under this section shall be published in the Federal Register.
    This section also directs the Secretaries to address a strategy
    for the comprehensive coordination of the behavioral health
    services provided by the Bureau of Indian Affairs and the
    Service, including the coordination of alcohol and substance
    abuse programs of the Service, the BIA, and Indian Tribes and
    Tribal Organizations developed under the Indian Alcohol and
    Substance Abuse Prevention and Treatment Act of 1986 with
    behavioral health initiatives pursuant to this Act.
        Amendments: This section maintains current law and adds
    language which (1) requires the Secretary to update existing
    memoranda of agreement; and (2) includes Tribal Organizations.
        Current Law: This section is Section 1621h(b) of current
    law.

    Section 703. Comprehensive behavioral health prevention and treatment
            program

        Section 703 requires the Secretary to provide a program of
    comprehensive behavioral health, prevention, treatment, and
    aftercare. Elements to be included in this program and target
    populations are specified. The Secretary may provide these
    services through Contract Health Services.
        Amendments: This section amends current law by (1)
    expanding beyond the alcohol and substance abuse focus to
    comprehensive behavioral health; and (2) adding more specific
    types of treatment. Language of current law, authorizing a
    grant to the Standing Rock Sioux Tribe to develop a community-
    based demonstration project, has been deleted.
        Current Law: This section is Section 1665a of current law.

    Section 704. Mental health technician program

        This section directs the Secretary to establish and
    maintain a mental health technician program within the Service
    to train and employ Indians as mental health technicians. The
    Secretary is to provide high-standard paraprofessional training
    in mental health care, supervise and evaluate the technicians,
    and ensure that the program involves the use and promotion of
    traditional health care practices of the Indian Tribes to be
    served.
        Amendments: This section maintains current law.
        Current Law: This section is Section 1621h(g) of current
    law.

    Section 705. Licensing requirement for mental health care workers

        This section requires that any individual employed as a
    psychologist, social worker, or marriage and family therapist
    for the purpose of providing mental health care services to
    Indians in a clinical setting under this Act to be licensed to
    provide these services. This section also sets forth
    requirements for individuals who may be employed as trainees in
    psychology, social work, or marriage and family therapy to
    provide mental health care services.
        Amendments: This section maintains current law.
        Current Law: This section is Section 1621h(l) of current
    law.

    Section 706. Indian women treatment programs

        This section authorizes the Secretary, consistent with
    section 701, to make grants to Tribes, Tribal Organizations and
    Urban Indian Organizations to develop and implement a
    comprehensive behavioral health program of prevention,
    intervention, treatment, and relapse prevention services that
    specifically address the cultural, historical, social, and
    child care needs of Indian women. Use of grant funds, criteria
    for applications for funding, and a specified amount of funding
    for grants to Urban Indian Organizations are also specified.
        Amendments: This section maintains current law and (1) adds
    language which requires the implementation of this section to
    be consistent with section 701; (2) recognizes the behavioral
    health focus, beyond just alcohol and substance abuse; and (3)
    requires consultation with Indian Tribes and Tribal
    Organizations in establishing criteria for the review and
    approval of applications.
        Current Law: This section is Section 1665b of current law.

    Section 707. Indian youth program

        This section requires the Secretary to develop and
    implement, consistent with section 701, a program for acute
    detoxification and treatment for Indian youth. The construction
    and staffing of alcohol and substance abuse treatment centers
    or facilities for Indian youths, including behavioral health
    services, is authorized. Additional provisions addressed in
    this section are: Construction and staffing of at least 1 youth
    regional treatment center in each IHS Area; the provision of
    intermediate adolescent behavioral health services; use of
    federally-owned structures for local residential or regional
    behavioral health treatment for Indian youths; the development
    and implementation of community-based rehabilitation and
    aftercare services; inclusion of family in youth treatment
    programs; programs and services to prevent and treat the abuse
    of multiple forms of substances among Indian youth; and data
    collection and a report to Congress concerning Indian youth and
    mental health services.
        Amendments: This section maintains current law and adds
    language which (1) requires implementation of this section to
    be consistent with section 701; (2) recognizes the behavioral
    health focus, beyond alcohol and substance abuse; (3) includes
    programs developed at the local tribal level; (4) includes
    treatment networks in addition to treatment programs; (5)
    includes sober or transitional housing in the intermediate
    adolescent services; (6) requires community reintegration as
    part of the rehabilitation and aftercare services; (7)
    establishes a program to prevent and treat multi-drug abuse;
    and (8) requires the Secretary to collect data for an Indian
    youth mental health report.
        Current Law: This section is Section 1665c of current law.

    Section 708. Indian youth telemental health demonstration project

        This section authorizes the Secretary to carry out a four-
    year demonstration project under which five Tribes or Tribal
    Organizations with telehealth capabilities could use telemental
    health services in youth suicide prevention and treatment. In
    awarding the grants, the Secretary would give priority to
    Tribes and Tribal Organizations serving a particular tribal
    community where there is a demonstrated need to address Indian
    youth suicide or which is isolated and has limited access to
    mental health services; entering into collaborative
    partnerships to provide the services; or operating a detention
    facility at which Indian youth are detained. The demonstration
    project would permit the use of telemedicine for psychotherapy,
    psychiatric assessments and diagnostic interviews of Indian
    youth; the provision of clinical expertise and other medical
    advice to frontline health care providers working with Indian
    youth; training and related support for community leaders,
    family members and health and education workers who work with
    Indian youth; the development of culturally-relevant
    educational materials on suicide prevention and intervention;
    and data collection and reporting.
        Amendments: This section is new and is not contained in
    current law.

    Section 709. Inpatient and community-based mental health facilities
            design, construction, and staffing

        This section allows the Secretary, not later than 1 year
    after the date of enactment, to provide, in each IHS Area, not
    less than 1 inpatient mental health care facility, or the
    equivalent, for Indians with behavioral health problems. The
    Secretary shall consider the possible conversion of existing
    underutilized hospital beds into psychiatric units to meet the
    needs.
        Amendments: This section amends current law by (1)
    requiring the establishment in each Area of at least 1
    inpatient mental health facility, rather than an assessment of
    the need; and (2) providing that California shall be considered
    two Area Offices.
        Current Law: Section 1621h(i) of current law provides that
    within one year after enactment, the Secretary shall make an
    assessment of the need for inpatient mental health care
    facilities.

    Section 710. Training and community education

        Section 710 requires that the Secretary, in cooperation
    with the Secretary of the Interior, develop and implement, or
    assist Indian Tribes and Tribal Organizations to develop and
    implement, a program of community education and involvement in
    the area of behavioral health. This section also addresses
    specifics of instruction and the development of community-based
    training models.
        Amendments: This section maintains current law and (1) adds
    language which authorizes the Indian Tribes and Tribal
    Organizations to develop training and community education
    programs; (2) adds child sexual abuse to the types of training
    authorized; and (3) recognizes the behavioral health focus of
    the program.
        Current Law: This section is Section 1621h(d) of current
    law.

    Section 711. Behavioral health program

        This section allows the Secretary, consistent with section
    701, to plan, develop, implement, and carry out programs to
    deliver innovative community-based behavioral health services
    to Indians. The section sets forth criteria to be used for
    grant awards for such programs, and requires that the same
    criteria as are used in evaluating other funding proposals be
    used for programs under this section.
        Amendments: This section maintains current law and adds
    Tribal Organizations as eligible recipients for funding under
    this section.
        Current Law: This section is Section 1621h of current law.

    Section 712. Fetal alcohol disorder programs

        Section 712 authorizes the Secretary, consistent with
    section 701, to establish and operate fetal alcohol disorder
    programs, to include the development and provision of services
    for the prevention, intervention, treatment, and aftercare for
    those affected by fetal alcohol disorder in Indian communities.
    Use of funds and criteria for applications are specified. In
    addition, the Secretary is directed to establish a Fetal
    Alcohol Disorder Task Force to advise the Secretary. This
    section also authorizes funding for applied research projects
    which propose to elevate the understanding of methods to
    prevent, intervene, treat or provide rehabilitation and
    aftercare for Indians affected by this disorder. Urban Indians
    are to receive a certain amount of funds appropriated for this
    program.
        Amendments: This section maintains current law and adds
    language (1) requiring these programs to be implemented
    consistent with section 701; (2) consolidating fetal alcohol
    syndrome and fetal alcohol effects into fetal alcohol disorders
    (FAD); (3) authorizing appropriate psychological services,
    early childhood intervention projects, community-based support
    services and housing as allowable uses of funding under this
    section; and (4) including the National Institute for Child
    Health and Human Development and the Centers for Disease
    Control and Prevention in the national Fetal Alcohol Disorder
    Task Force. Provisions of current law establishing a national
    clearinghouse for prevention and educational materials and
    other information on FAS and FAE effect in Indian and Alaska
    Native communities, and requirements for a report to Congress
    contained in current law have been deleted.
        Current Law: This section is Section 1665g of current law.

    Section 713. Child sexual abuse and prevention treatment programs

        This section directs the Secretary to establish, consistent
    with section 701, treatment programs in every IHS Area for both
    Indian victims of child sexual abuse and Indian perpetrators of
    child sexual abuse. This section specifies the use of funds for
    these programs, and directs that they be carried out in
    coordination with programs and services authorized under the
    Indian Child Protection and Family Violence Prevention Act (25
    U.S.C. 3201 et seq.).
        Amendments: This section amends current law by (1) turning
    two specific demonstration projects into permanent programs;
    (2) making the establishment of these programs consistent with
    section 701; (3) authorizing services for Indian child victims
    of sexual abuse and perpetrators of child sexual abuse who are
    members of an Indian household; (4) including authorized uses
    of funds such as developing community education, identifying
    and providing treatment to victims, developing culturally-
    sensitive prevention models and diagnostic tools, and providing
    treatment to the perpetrators; and (5) providing that these
    programs are carried out in coordination with programs and
    services authorized under the Indian Child Protection and
    Family Violence Prevention Act.
        Current Law: Section 1680i of current law establishes
    demonstration programs involving treatment for child sexual
    abuse through the Hopi Tribe and the Assiniboine and Sioux
    Tribes of the Fort Peck Reservation. The Secretary may
    establish other demonstration projects, but must have an equal
    number of projects for the IHS Areas.

    Section 714. Behavioral health research

        Section 714 authorizes the Secretary to make grants to, or
    enter into contracts with, Indian Tribes, Tribal Organizations,
    and Urban Indian Organizations or enter into contracts with, or
    make grants to appropriate institutions for, the conduct of
    research on the incidence and prevalence of behavioral health
    problems among Indians. Research priorities are specified,
    including youth suicide, the interrelationship of mental
    disorders with alcoholism, suicide, homicide, and the incidence
    of family violence, and prevention models.
        Amendments: This section maintains current law and adds
    language which emphasizes the focus on behavioral health
    instead of only mental health problems.
        Current Law: This section is Section 1621h of current law.

    Section 715. Definitions

        This section provides definitions for the following terms
    used in this title: assessment; alcohol-related
    neurodevelopmental disorders or ARND; behavioral health
    aftercare; dual diagnosis; fetal alcohol disorders; fetal
    alcohol syndrome or FAS; partial FAS; rehabilitation; and
    substance abuse.
        Amendments: This section is new and is not contained in
    current law.

    Section 716. Authorization of appropriations

        This section authorizes to be appropriated such sums as may
    be necessary for each fiscal year through fiscal year 2017 to
    carry out this title.
        Amendments: This section maintains current law and extends
    the authorization from fiscal year 2000 to fiscal year 2017 and
    eliminates the exceptions for sections that had specific terms
    of authorization.
        Current Law: This section is Section 1621w of current law.

                           TITLE VIII--MISCELLANEOUS

    Section 801. Reports

        This section outlines requirements under this Act for
    various reports (and their contents) and audits which shall be
    submitted to Congress.
        Amendments: This section maintains current law and adds
    provisions which either establish new reporting requirements or
    consolidate the information required in other sections in one
    organized list, such as requiring as part of the annual reports
    to Congress information on services provided under Indian Self-
    Determination Act agreements, loan repayment programs,
    infectious diseases, environmental hazards, status of health
    care and sanitation facilities, sharing of services between the
    IHS and other federal agencies, and urban Indian programs.
        Current Law: This section is Section 1671 of current law.

    Section 802. Regulations

        This section sets forth the various requirements for
    regulations, including regulations developed through negotiated
    rulemaking, for selected titles and sections, and timelines for
    issuance of regulations under this Act. The membership of the
    negotiated rulemaking committee and its procedures are
    delineated.
        Amendments: This section is new and is not contained in
    current law.

    Section 803. Plan of implementation

        This section requires the Secretary, in consultation with
    Indian Tribes, Tribal Organizations, and Urban Indian
    Organizations, to submit to Congress a plan of implementation
    of this Act within 9 months.
        Amendments: This section is new and is not contained in
    current law.

    Section 804. Availability of funds

        This section authorizes funds appropriated pursuant to this
    Act to remain available until expended.
        Amendments: This section maintains current law.
        Current Law: This section is Section 1675 of current law.

    Section 805. Limitation on use of funds appropriated to Indian Health
            Service

        This section provides that any limitation on the use of
    funds contained in an Act that provides appropriations for the
    Department of Health and Human Services with respect to the
    performance of abortions shall apply for that fiscal year to
    the performance of abortions using funds contained in an Act
    providing appropriations for the Service.
        Amendments: This section maintains current law.
        Current Law: This section is Section 1676 of current law.

    Section 806. Eligibility of California Indians

        This section clarifies the eligibility of California
    Indians for health services provided by the Service to include
    members of federally-recognized tribes, descendants of Indians
    residing in California as of June 1, 1852, Indians holding
    trust interests in certain types of land, and Indians listed on
    the plans for assets distribution in California.
        Amendments: This section maintains current law, but
    eliminates the report to Congress developing data on the
    Indians located in California, health status and needs and
    other information.
        Current Law: This section is Section 1679 of current law.

    Section 807. Health services for ineligible persons

        This section authorizes services for certain persons (such
    as children and spouses) and other individuals otherwise
    ineligible for health services provided by the Service under
    limited circumstances, and outlines criteria for providing and
    paying for those services.
        Amendments: This section maintains current law and adds
    compacts, in addition to contracts, entered in to under the
    Indian Self-Determination Act.
        Current Law: This section is Section 1680c of current law.

    Section 808. Reallocation of base services

        This section requires the Secretary to submit a report to
    Congress on any allocation of Service funds for a fiscal year
    that reduces by 5% or more from the previous fiscal year the
    funding for any recurring program, project, or activity of a
    Service Unit.
        Amendments: This section maintains current law.
        Current Law: This section is Section 1680g of current law.

    Section 809. Results of demonstration projects

        This section requires the Secretary to disseminate to
    Indian Tribes, Tribal Organizations, and Urban Indian
    Organizations the findings and results of demonstration
    projects conducted under this Act.
        Amendments: This section maintains current law, and adds
    Tribal Organizations and Urban Indian Organizations.
        Current Law: This section is Section 1680m of current law.

    Section 810. Provision of services in Montana

        This section recognizes a court decision governing the
    provision of services and benefits for certain Indians in
    Montana.
        Amendments: This section is new and is not contained in
    current law.

    Section 811. Moratorium

        This section authorizes the Service to provide certain
    health care services according to eligibility criteria in
    effect on a certain date until the Service submits to Congress
    and the Congress enacts an appropriations Act that reflects the
    increased costs associated with the Department's proposed final
    rule, implementing other eligibility criteria.
        Amendments: This section is new and is not contained in the
    current Indian health law. However, similar language has
    appeared for several years in Interior Appropriations Acts.

    Section 812. Tribal employment

        This section provides that an Indian Tribe or Tribal
    Organization carrying out a contract or compact pursuant to the
    Indian Self-Determination and Education Assistance Act shall
    not be considered an ``employer.''
        Amendments: This section is new and is not contained in
    current law.

    Section 813. Severability provisions

        This section retains remaining provisions of the Act if
    other provisions are stricken by any court.
        Amendments: This section is new and is not contained in
    current law.

    Section 814. Establishment of national bipartisan commission on Indian
            health care

        This section establishes a Commission to study the delivery
    of health care services to Indians, and sets forth the duties,
    membership, compensation, and meeting, hearing and reporting
    requirements. This section also authorizes the appointment of a
    Director and staff for the Commission; establishes their
    compensation; and authorizes details of federal employees,
    hearings, use of mails, technical assistance and administrative
    support services. $4 million is authorized for the Commission.
        Amendments: This section is new and is not contained in
    current law.

    Section 815. Confidentiality of medical quality assurance records;
            qualified immunity for participants

        This section would establish requirements for quality
    assurance such as confidentiality, privacy, disclosure and
    liability. Section 815 also sets forth the limits of such
    disclosure.
        Amendments: This section is new and is not contained in
    current law.

    Section 816. Appropriations; availability

        This section subjects new spending authority to amounts
    provided in appropriations Acts.
        Amendments: This section is new and is not contained in
    current law.

    Section 817. Authorization of appropriations

        This section authorizes to be appropriated such sums as may
    be necessary for each fiscal year through fiscal year 2017 to
    carry out this title.
        Amendments: This section maintains current law and extends
    the authorization through fiscal year 2017.
        Current Law: Section 1680o authorizes appropriations
    through fiscal year 2000.

    Section 101(b). Indian Health Care Improvement Act amended

        Section 101(b) includes provisions amending other laws for
    the references to the ``Director of Indian Health Service''
    which would be changed to ``Assistant Secretary for Indian
    Health''.
        Amendments: This section is new and is not contained in
    current law.

    Section 102. Soboba sanitation facilities

        Section 102 authorizes sanitation facilities and services
    to be provided to the Soboba Band of Mission Indians and the
    Soboba Indian Reservation.
        Amendments: This section is new and is not contained in
    current law.

    Section 103. Native American Health and Wellness Foundation

        Section 103 amends the Indian Self-Determination and
    Education Assistance Act to include a new Title VIII under
    which a Native American Health and Wellness Foundation would be
    established, in the following sections:
    Section 801. Definitions
        This section includes definitions for the Board, Committee,
    Foundation, and other terms used in this section.
    Section 802. Native American Health and Wellness Foundation
        This section establishes the perpetual existence of the
    Foundation, the nature and duties of the Foundation and the
    place of incorporation. This section also authorizes the
    Secretary to establish an initial Committee to assist in
    establishing the Foundation. Section 802 establishes the
    authority of the Board of Directors, including their terms, the
    officers (including the extent of their liabilities) and the
    powers of the Foundation. This section also establishes limits
    on the administrative costs, audit requirements, and authorizes
    $500,000 for the fiscal years.
    Section 803. Administrative services and support
        This section authorizes the Secretary to provide
    administrative support to the Foundation and initial operating
    funds on a reimbursement basis for up to five years.

        Amendments: This section is new and is not contained in
    current law.

                                    Title II

        Title II of the bill is amendments to the Social Security
    Act that is under the jurisdiction of the Senate Finance
    Committee. These provisions include waivers of cost-sharing and
    premiums for Medicaid for Indians receiving services at IHS,
    tribal or urban Indian health programs, Medicaid managed care
    provisions, and safe harbor protections from the anti-kickback
    statutes.

    Section 201. Expansion of payments under Medicare, Medicaid and SCHIP
            for all covered services furnished by Indian health programs

        Section 201 authorizes IHS, tribal and urban Indian health
    programs to be reimbursed for Medicaid, if the services meet
    the conditions and requirements generally applicable to the
    delivery of such care. In addition, this section requires IHS,
    tribal or urban Indian health facilities to make improvements
    to achieve or maintain compliance. The Secretary is also
    authorized to enter into an agreement with a State to reimburse
    the State for Medicaid services provided by the IHS, tribal or
    urban Indian health programs. This section cross-references the
    special fund to which Medicaid reimbursements are placed for
    IHS and direct billing requirements for the IHS and tribal
    health programs under the Act. This section also authorizes
    Medicare payments to IHS, tribal and urban Indian health
    programs so long as they are compliant with Medicare
    requirements. The section cross-references the Act's provisions
    under which Medicare payments made are placed in a special fund
    for the purpose of making improvements to maintain compliance.

    Section 202. Increased outreach to Indians under Medicaid and SCHIP and
            improved cooperation in the provision of items and services to
            Indians under Social Security Act health benefit programs

        Section 202 authorizes the Secretary to encourage States to
    take steps to increase enrollment and outreach for Indian
    children in the State Children's Health Insurance Program and
    requires the Secretary to facilitate cooperation between States
    and the IHS, tribal and urban Indian health programs.

    Section 203. Additional provisions to increase outreach to, and
            enrollment of, Indians in SCHIP and Medicaid for outreach

        Section 203 excludes certain activities, such as outreach
    activities for families of Indian children likely to be
    eligible for SCHIP and enrollment assistance activities, from
    the current 10% cap on certain SCHIP payments.

    Section 204. Premiums and cost sharing protections under Medicaid,
            eligibility determinations under Medicaid and SCHIP, and
            protection of certain Indian property from Medicaid estate
            recovery

        Section 204 prohibits the imposition of enrollment fees,
    premiums and cost-sharing on Indians served at the IHS, tribal
    or urban Indian health programs or through the referrals to
    contract health and the reduction of the reimbursement to the
    IHS, tribal or urban Indian health program for the fees or
    cost-sharing. In addition, this section exempts certain Indian
    property, such as trust land, from being included in
    determining eligibility of an individual who is an Indian for
    Medicaid, and continues protections of certain Indian property
    from Medicaid estate recovery.

    Section 205. Nondiscrimination in qualifications for payment for
            services under Federal health care programs

        Section 205 allows the IHS, Tribal or urban Indian health
    programs to be accepted on the same basis as any other provider
    eligible for reimbursement, if the program meets generally
    applicable participation requirements. The provision would
    prohibit payments if the program was excluded from any other
    Federal health care program and if any State licenses were
    suspended or revoked.

    Section 206. Consultation on Medicaid, SCHIP, and other health care
            programs funded under the Social Security Act involving Indian
            health programs and urban Indian organizations

        Section 206 maintains the Tribal Technical Advisory Group
    established to provide technical assistance or advice to the
    Centers for Medicare and Medicaid Services. This section also
    requires the States to establish a process for consultation
    with the tribal or urban Indian health programs on matters
    relating to Medicaid which are likely to have a direct effect
    on Indians or Indian health programs.

    Section 207. Exclusion waiver authority for affected Indian health
            programs and safe harbor transactions under the Social Security
            Act

        Section 207 establishes a process whereby the administrator
    of an Indian Health Program may request a waiver of sanctions
    imposed on a health provider. This section also specifies that
    certain transactions not be considered remuneration under
    Section 1128B(b) of the Social Security Act for certain
    transfers between the Indian health programs or patient for the
    purpose of providing necessary health care services to the
    patient.

    Section 208. 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

        Section 208 allows Indians, enrolled in a non-Indian
    Medicaid managed care entity (MCE) with an Indian health
    program participating in the network, to choose the Indian
    health program as the primary care provider. It also requires
    MCEs with significant Indian enrollees to meet other
    requirements. The Indian health programs would also be required
    to comply with all generally applicable Medicaid requirements
    to the extent the requirements do not conflict with other
    Federal statutes applicable to the Indian health programs. This
    section also sets forth special rules applicable to Indian
    MCEs, such as the ability to restrict enrollment to Indians and
    other enrollment rules. In regard to 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 would be deemed to
    satisfy such a requirement if it is an FQHC covered under the
    Federal Tort Claims Act, a provider that delivers services
    pursuant to a contract under the Indian Self-Determination and
    Education Assistance Act, or the Indian Health Service, which
    is covered under the Federal Tort Claims Act.

    Section 209. Annual report on Indians served by Social Security Act
            health benefit programs

        Section 209 requires annual reports to Congress regarding
    the enrollment and health status of Indians receiving items or
    services under the health benefit programs.

                              Legislative History

        On April 24, 2007, Senators Dorgan, Thomas, Boxer, Reid,
    Cantwell, Johnson, Tester, Inouye, Domenici, Bingaman, Baucus,
    Klobuchar, Obama and Murkowski introduced S. 1200, the Indian
    Health Care Improvement Act Amendments of 2007. Senators
    Cochran and Murray were added as cosponsors on April 26, 2007;
    Senator Clinton on May 3, 2007; and Senators Brown and Stevens
    on May 21, 2007. Senator Stabenow was added as a cosponsor on
    September 4, 2007.
        The Committee held a hearing on the Indian Health Care
    Improvement Act on March 8, 2007. This was the tenth hearing
    since the 106th Congress on the reauthorization of the Act.
        On May 10, 2007, the Committee on Indian Affairs convened a
    business meeting to consider S. 1200 and other measures that
    had been referred to it, and ordered the bill favorably
    reported.

                Committee Recommendation and Tabulation of Vote

        On May 10, 2007, the Committee on Indian Affairs convened a
    business meeting to consider S. 1200 and other measures, and
    voted to have the bill favorably reported to the full Senate,
    without amendment, with the recommendation that the bill do
    pass.

                   Regulatory and Paperwork Impact Statement

        Paragraph 11(b) of rule XXVI of the Standing Rules of the
    Senate requires that each report accompanying a bill evaluate
    the regulatory and paperwork impact that would be incurred in
    carrying out the bill. The Committee has concluded that S. 1200
    will not require the promulgation of regulations so the
    regulatory and paperwork impact should be minimal.

                            Executive Communications

        On May 1, 2007, Chairman Dorgan sent letters to both
    Secretary Michael Leavitt and Attorney General Gonzales, asking
    the Department of Health and Human Services and the Department
    of Justice to provide the Committee with their views on S.
    1200.
        The Department of Justice submitted a letter of comments on
    June 13, 2007, which is attached, below.

                                 Department of Justice,
                                 Office of Legislative Affairs,
                                         Washington, DC, June 13, 2007.
    Hon. Byron L. Dorgan,
    Chairman, Committee on Indian Affairs,
    U.S. Senate, Washington, DC.
        Dear Mr. Chairman: Thank you for the opportunity to comment
    upon S. 1200, the Indian Health Care Improvement Act Amendments
    of 2007. The Department of Justice fully supports the purposes
    of this legislation--improving access to health care for
    American Indians and Alaska natives. The Department has worked
    with the Committee on Indian Affairs on previous versions of
    this legislation and believes that most of its prior concerns
    have been addressed by S. 1200. The Department does, however,
    continue to have a few concerns with the legislation that we
    have noted in the past. As explained below, the Department
    believes that these concerns can be addressed with relatively
    modest changes to bill language that would not detract from the
    overall goal of improving health care for Native Americans but
    would, in the Department's view, benefit both the Native
    American community specifically and taxpayers generally.
        1. The legislation authorizes funding and encourages the
    use of traditional health care practices. The Department does
    not oppose the provision of traditional health care practices
    as an adjunct to ``Western'' medical practices. We note that on
    March 8, 2007, Ms. Rachel Joseph, Co-Chairperson of the
    National Steering Committee for the Reauthorization of the
    Indian Health Care Improvement Act, testified that
    ``[t]raditional health care practices are usually provided as
    complementary services to Western medical practices at the
    request of family members.'' Ms. Joseph also testified that
    ``[i]n most cases, the traditional health care practitioners
    are not employees of the IHS or tribes so FTCA coverage would
    not apply in the event that a malpractice claim was ever
    filed.''
        A prior version of this legislation contained language
    clarifying that traditional health care practitioners are not
    covered by the Federal Tort Claims Act (``FTCA''), and we
    recommend that this language be added back to S. 1200.
    Specifically, we recommend the following provision as an
    addition to section 805:
        (b) No Liability.--Although the Secretary may promote
    traditional health care practices, consistent with the Service
    standards for the provision of health care, health promotion,
    and disease prevention under this Act, the United States is not
    liable for the acts or omissions of any person in providing
    traditional health care practices under this Act that result in
    damage, injury, death, or any outcome to any patient.
        This language is intended to confirm existing law that
    there is no valid cause of action under the FTCA for injuries
    resulting from traditional tribal healing practices provided
    pursuant to self determination contracts because state law
    generally does not make private parties liable for
    ``malpractice'' involving traditional tribal healing practices.
    See 28 U.S.C. Sec. 2674. Thus, this provision would ensure that
    the United States would not face potential tort liability for
    the provision of treatment through traditional health care
    practices for which no state standard of care exists and would
    prevent costly litigation about whether the United States could
    be held liable under the FTCA for such practices. Moreover, it
    would preclude intrusive discovery regarding the nature and
    purpose of traditional health care practices. Such litigation
    would almost certainly raise questions as to the advisability
    of Tribal health practices and potentially create unnecessary
    conflict between these practices and Western medical standards.
    Additionally, we believe the proposed language would ameliorate
    any Tribal sovereignty concerns that would arise in FTCA
    litigation regarding inquiry into traditional health care
    practices. At the same time, this language would not scale back
    in any way the current liability protections that the Tribes
    enjoy in carrying out self-determination contracts.
        We also have concerns regarding changes made to section 213
    of the legislation. The current version of section 213(b)(1)
    was modified to provide:
        (b) Terms and Conditions.--
        (1) In general.--Any service provided under this section
    shall be in accordance with such terms and conditions as are
    consistent with accepted and appropriate standards relating to
    the service, including any licensing term or condition required
    under this Act.
        The previous version of the legislation, unlike S. 1200,
    made explicit that the Secretary ``shall require'' that any
    service provided be in accordance with terms and conditions
    that the Secretary determined to be consistent with accepted
    and appropriate standards relating to the service. We think S.
    1200 is unclear in this regard, as it fails to explicitly
    specify who is responsible for requiring that any services
    provided are in accordance ``with such terms and conditions as
    are consistent with the accepted and appropriate standards
    relating to the service.'' We suggest revising subsection
    213(b)(1) to provide:
        (1) In general.--The Secretary shall require that any
    service provided pursuant to this Act is in compliance with the
    accepted and appropriate standards relating to the service,
    including any licensing term or condition under this Act.
        Relatedly, S. 1200 made changes to the prior language of
    subsection 213(b)(2). That subsection now reads:
        (b)(2)(A) Standards.--
        In general.--The Secretary may establish, by regulation,
    the standards for a service provided under this section,
    provided that such standards shall not be more stringent than
    the standards required by the State in which the service is
    provided.
        We have concerns about this language. For the purposes of
    tort liability under the FTCA, state law provides the standards
    governing the conduct at issue. If the Secretary, by
    regulation, establishes standards that fall below the standards
    required by the State, there is a risk the United States could
    be held liable under the FTCA, even if the care complied with
    the standards promulgated by the Secretary. Moreover, and more
    likely troublesome, if the Secretary approves services for
    which there are no applicable state standards, subsection
    (b)(2), by its plain language, would appear to prevent the
    Secretary from establishing any appropriate standards because
    those standards would, by their very existence, be more
    stringent than what is required by the State. Where no state
    standards are applicable, it is in the interests of both the
    United States and the Tribes to whom such services might be
    provided to have some applicable and appropriate standards of
    care set by the Secretary. Thus, along with the Department of
    Health and Human Services, we propose working with the
    Committee to revise subsection (b)(2)(A) to address this
    concern.
        Finally, S. 1200 also includes this new provision to
    section 213:
        (b)(2)(B) Use of State Standards.--
        If the Secretary does not, by regulation, establish
    standards for a service provided under this section, the
    standards required by the State in which the service is or will
    be provided shall apply to such service.
        We agree that state standards should be applicable, since
    liability under the FTCA would be measured by those standards.
    Again, however, if there is no applicable state standard, the
    Secretary should be permitted to set some meaningful and
    appropriate standard of care, which is arguably not possible
    given the limitation of subsection (b)(2)(A).
        2. The Department believes that the legislation continues
    to raise a constitutional concern to the extent that it
    provides government benefits to individuals who are not members
    of, or closely affiliated with, a Federally recognized Indian
    tribe. As the Department has noted in the past, the Supreme
    Court has held that classifications based on affiliation with a
    Federally recognized tribe are ``political rather than
    racial,'' and therefore will be upheld as long as there is a
    rational basis for them. To the extent, however, that programs
    benefiting ``Urban Indians'' under this legislation could be
    viewed as authorizing the award of grants and other Government
    benefits on the basis of racial or ethnic criteria, rather than
    tribal affiliation, these programs would be subject to strict
    scrutiny under the equal protection component of the Due
    Process Clause. Both this bill and the current statute broadly
    define ``Urban Indian'' to include individuals who are not
    necessarily affiliated with a federally recognized Indian
    tribe. Under the Supreme Court's decisions, there is a
    substantial likelihood that legislation providing special
    benefits to individuals of Indian or Alaska Native descent who
    do not have a clear and close affiliation with a federally
    recognized tribe would be regarded by the courts as creating a
    racial preference subject to strict constitutional scrutiny,
    rather than a political preference subject to rational basis
    review. In the event the legislation is regarded as awarding
    Government benefits based on a racial classification, it would
    be constitutional only if the bill is supported by a factual
    record demonstrating that its use of race-based criteria to
    award the benefits at issue is ``narrowly tailored'' to serve a
    ``compelling'' Government interest.
        The bill's extension of benefits to members of State-
    recognized tribes raise the same concern. As a threshold
    matter, it is not clear whether the courts would agree that
    Congress can constitutionally delegate its tribal recognition
    authority to the States and, even if Congress can do so as a
    general matter, the delegation in this bill would allow States
    to designate as ``tribal members'' eligible for Federal
    benefits individuals who: (i) do not belong to a ``distinctly
    Indian community'' or other group that conforms to the Supreme
    Court's definitions of ``the Indian tribes'' referenced in the
    Commerce Clause, but instead are considered a member of a State
    ``tribe'' solely on the basis of race or affiliation with a
    group that lacks the sovereign attributes the Supreme Court has
    identified as important to classification as an ``Indian
    tribe'' for purposes of Commerce Clause legislation; and/or
    (ii) are otherwise outside the class of beneficiaries that
    Congress intended to reach with this bill. In this regard, as
    you may know, the American Indian Heritage Support Center
    (``AIHSC''), in a March 29, 2007, letter to the Department,
    with copies to Members of Congress, voiced concerns about the
    extension of benefits under this legislation to ``state
    recognized tribes'' because, according to the AIHSC, some of
    these ``tribes'' ``have no historical background past the last
    10 to 20 years'' and simply seek ``tribal'' recognition to take
    advantage of certain recent Government benefits such as gaming
    privileges.
        The Department recommends that, consistent with the settled
    practice of avoiding unnecessary constitutional issues,
    Congress revise the bill to extend benefits only to individuals
    who, in addition to satisfying whatever other criteria Congress
    may wish to impose, qualify as ``members of, or individuals
    having a clear and close affiliation with, a federally-
    recognized tribe.'' Such a revision would avoid the
    constitutional concerns outlined above in a way that the
    Department believes would not detract from the overall goal of
    improving health care for Native Americans, and might actually
    better ensure that benefits under the bill would extend only to
    the class of beneficiaries contemplated by Congress and the
    Constitution.
        Thank you for the opportunity to comment upon this very
    important legislation. We are committed to working with the
    Committee to have this legislation passed. The Office of
    Management and Budget has advised us that there is no objection
    to this letter from the perspective of the Administration's
    program.
                Sincerely,
                                           Richard A. Hertling,
                           Principal Deputy Assistant Attorney General.
        The Committee has not received any formal communication on
    S. 1200 from the Department of Health and Human Services other
    than the testimony presented to the Committee at the hearing on
    reauthorization of the Indian Health Care Improvement Act on
    March 8, 2007, which is also attached, below.

        Statement of Admiral John O. Agwunobi, MD, MBA, MPH, Assistant
       Secretary for Health, U.S. Department of Health and Human Services

        Mr. Chairman and Members of the Committee: My name is John
    Agwunobi and I am the Assistant Secretary for Health for the
    U.S. Department of Health and Human Services (HHS). As the
    Assistant Secretary, I serve as the Secretary's primary advisor
    on matters involving the nation's public health. I also oversee
    the U.S. Public Health Service and its Commissioned Corps for
    the Secretary.
        This landmark legislation forms the backbone of the system
    through which Federal health programs serve American Indians/
    Alaska Natives and encourages participation of eligible
    American Indians/Alaska Natives in these and other programs.
        The IHS has the responsibility for the delivery of health
    services to more than 1.8 million Federally-recognized American
    Indians/Alaska Natives through a system of IHS, tribal, and
    urban (I/T/U) health programs governed by judicial decisions
    and statutes. The mission of the agency is to raise the
    physical, mental, social, and spiritual health of American
    Indian/Alaska Natives to the highest level, in partnership with
    the population we serve. The agency goal is to assure that
    comprehensive, culturally acceptable personal and public health
    services are available and accessible to the service
    population. Our duty is to uphold the Federal government's
    responsibility to promote healthy American Indian and Alaska
    Native people, communities, and cultures and to honor and
    protect the inherent sovereign rights of Tribes.
        Two major statutes are at the core of the Federal
    government's responsibility for meeting the health needs of
    American Indians/Alaska Natives: The Snyder Act of 1921, P.L.
    67-85, and the Indian Health Care Improvement Act (IHCIA), P.L.
    94-437, as amended. The Snyder Act authorized regular
    appropriations for ``the relief of distress and conservation of
    health'' of American Indians/Alaska Natives. The IHCIA was
    enacted ``to implement the Federal responsibility for the care
    and education of the Indian people by improving the services
    and facilities of Federal Indian health programs and
    encouraging maximum participation of Indians in such
    programs.'' Like the Snyder Act, the IHCIA provides the
    authority for the Federal government programs that deliver
    health services to Indian people, but it also provides
    additional guidance in several areas. The IHCIA contains
    specific language addressing the recruitment and retention of
    health professionals serving Indian communities; the provision
    of health services; the construction, replacement, and repair
    of health care facilities; access to health services; and the
    provision of health services for urban Indian people.

                                dhhs activities

        Since enactment of the IHCIA in 1976, Congress has
    substantially expanded the statutory authority for programs and
    activities in order to keep pace with changes in healthcare
    services and administration. Federal funding for the IHCIA has
    contributed billions of dollars to improve the health status of
    American Indians/Alaska Natives. And, much progress has been
    made particularly in the areas of infant and maternal
    mortality.
        The Department under this Administration's leadership
    reactivated the Intradepartmental Council on Native American
    Affairs (ICNAA) to provide for a consistent HHS policy when
    working with the more than 560 Federally recognized Tribes.
    This Council's vice chairperson is the IHS Director, giving him
    a highly visible role within the Department on Indian policy.
        In January of 2005 the Department completed work ushering
    through a revised HHS Tribal consultation policy and involving
    Tribal leaders in the process. This policy further emphasizes
    the unique government-to-government relationship between Indian
    Tribes and the Federal government and assists in improving
    services to the Indian community through better communications.
    Consultation may take place at many different levels. To ensure
    the active participation of Tribes in the development of the
    Department's budget request, an HHS-wide budget consultation
    session is held annually. This meeting provides Tribes with an
    opportunity to meet directly with leadership from all
    Department agencies and identify their priorities for upcoming
    program requests. For FY 2008, Tribes identified population
    growth and increases in the cost of providing health care as
    their top budget priorities and IHS's FY 2008 budget request
    included an increase of $88 million for these items.
        Through the Centers for Medicare & Medicaid Services (CMS),
    a Technical Tribal Advisory Group was established which
    provides Tribes with a vehicle for communicating concerns and
    comments to CMS on Medicare, Medicaid and SCHIP policies
    impacting their members. And the IHS has been vigilant about
    improving outcomes for Indian children and families with
    diabetes by increasing education and physical activity programs
    aimed at preventing and addressing the needs of those
    susceptible to, or struggling with, this potentially disabling
    disease. In addition, a Tribal Leaders Diabetes Committee
    continues to meet several times a year at the direction of the
    IHS Director to review information on the progress of the
    Special Diabetes Program for Indians activities and to provide
    general recommendations to IHS.
        It is clear the Department has not been a passive observer
    of the health needs of eligible American Indians/Alaska
    Natives. Yet, we recognize that health disparities among this
    population do exist and are among some of the highest in the
    Nation for certain diseases (e.g., alcoholism, cardiovascular
    disease, diabetes, and injuries), and that improvements in
    access to IHS and other Federal and private sector programs
    will result in improved health status for Indian people.
        The IHCIA was enacted to provide primary and preventive
    services in recognition of the Federal government's unique
    relationship with members of Federally recognized Tribes.
    Members of Federally recognized Tribes and their descendants
    are also eligible for other Federal health programs (such as
    Medicare, Medicaid and SCHIP) on the same basis as other
    Americans, and many also receive health care through employer-
    sponsored or other healthcare coverage.
        It is within the context of current law and programs that
    we turn our attention to reauthorization of the ``Indian Health
    Care Improvement Act.''

                                reauthorization

        We are here today to discuss reauthorization of the IHCIA,
    and its impact on programs and services provided for in current
    law. In December of 2006, the Department submitted to this
    Committee comments on proposed legislation that the 109th
    Congress was considering. These comments are the basis for our
    testimony today, and any changes introduced by the bill under
    review in the 110th Congress will be considered once we have
    had an opportunity to review newly introduced legislation.
    Improving access to healthcare for all eligible American
    Indians and Alaska Natives is a priority for all those involved
    in the administration of the IHS program. We have worked
    closely with this Committee in the past and we have made
    progress in moving toward a program supportive of existing
    authority while maintaining the Secretary's flexibility to
    effectively manage the IHS program. However, in the last bill,
    S. 1057, there continued to be provisions which could
    negatively impact our ability to provide needed access to
    services. Such provisions established program mandates and
    burdensome requirements that could, or would, divert resources
    from important services. To the extent that those provisions
    are included in the new legislation, we hope to work with you
    to continue to address these concerns.
        The Department is supportive of reauthorization of the
    IHCIA and supports provisions that maintain or increase the
    Secretary's flexibility to work with Tribes, and to increase
    the availability of health care. Committee leadership
    previously responded to some concerns raised about certain
    provisions and some of the changes went a long way toward
    improving the Secretary's ability to effectively manage the
    program within current budgetary resources.
        I would like to note for you today our particular interest
    in provisions previously reported out of this Committee.

                              overarching concerns

        We have a number of general objections to previous
    language, including, expanded requirements for negotiated
    rulemaking and consultation; new requirements using ``shall''
    instead of ``may''; use of the term ``funding'' in place of
    ``grant''; expansion of authorities for Urban Indian
    Organizations; new permissive authorities; provisions governing
    traditional health care practices; new reporting requirements;
    establishment of the Bipartisan Commission on Indian Health
    Care; and new provisions that contemplate the Secretary
    exercising authority through the Service, Tribes and Tribal
    Organizations which is not tied to agreements entered into
    under the Indian Self-Determination and Education Assistance
    Act (ISDEAA). In addition, we noted concerns in previous
    language about modifying current law with respect to Medicaid
    and the State Children's Health Insurance Program (SCHIP) and,
    in some cases, we believe maintaining the current structure of
    Medicaid and the State Children's Health Insurance Program
    (SCHIP) preserves access, delivery, efficiency, and quality of
    services to American Indians.
        We also have some more specific comments on proposals we
    have previously reviewed for comment.
        In the area of behavioral health, proposed title VII
    provisions provided for the needs of Indian women and youth and
    expands behavioral health services to include a much needed
    child sexual abuse and prevention treatment program. The
    Department supports this effort, but opposes language in
    Sections 704, 706, 711(b) and 712 that requires the
    establishment or expansion of specific additional services. The
    Department should be given the flexibility to provide for all
    Behavioral Health Programs in a manner that supports the local
    control and priorities of Tribes, and to address their specific
    needs within IHS overall budgetary levels.

                             reporting requirements

        The last version of S. 1057 that we reviewed contained
    various new requirements for reporting to Congress, including
    requirements for specific information to be included within the
    President's Budget and a new annual report to Congress by the
    Centers for Medicare & Medicaid Services and the IHS on Indians
    served by Social Security Act health benefit programs. The IHS,
    CMS, and HHS will work with Congress to provide the most
    complete and relevant information on IHS programs, activities,
    and performance and other Indian health matters. However, we
    recommend striking language that requires additional
    specificity about what should be included in the President's
    budget request and new requirements for annual reports.

                                   facilities

        Sanitation facilities construction is conducted in 38
    States with Federally recognized Tribes who take ownership of
    the facilities to operate and maintain them once completed. IHS
    and Tribes operate 49 hospitals, 247 health centers, 5 school
    health centers, over 2000 units of staff housing, and 309
    health stations, satellite clinics, and Alaska village clinics
    supporting the delivery of health care to Indian people.

                health care facilities needs assessment & report

        One provision in last year's bill, section 301(d)(1),
    required Government Accountability Office (GAO) to complete a
    report, after consultation with Tribes, on the needs for health
    care facilities construction, including renovation and
    expansion needs. However, efforts are currently underway to
    develop a complete description of need similar to what would
    have been required by the bill. The IHS plan is to base our
    future facilities construction priority system methodology
    application on a more complete listing of tribal and Federal
    facilities needs for delivery of health care services funded
    through the IHS. We will continue to explore with the Tribes
    less resource intensive means for acquiring and updating the
    information that would be required in these reports.
        We recommend the deletion of the reference to the
    Government Accountability Office undertaking the report because
    it would be redundant of and a setback for IHS's current
    efforts to develop an improved facilities construction
    methodology.

           retroactive funding of joint venture construction projects

        In last year's bill, section 311(a)(1) would permit a tribe
    that has ``begun or substantially completed'' the process of
    acquisition of a facility to participate in the Joint Venture
    Program, regardless of government involvement or lack thereof
    in the facility acquisition. A Joint Venture Program agreement
    implies that all parties have participated in the development
    of a plan and have arrived at some kind of consensus regarding
    the actions to be taken. By permitting a tribe that has ``begun
    or substantially completed'' the process of acquisition or
    construction, the proposed provisions could force IHS to commit
    the government to support already completed actions that have
    not included the government in the review and approval process.
    We are concerned that this language could put the government in
    the position of accepting space that is inefficient or
    ineffective to operate. We, therefore, would oppose such a
    provision.

                  sanitation facilities deficiency definitions

        Another section 302(h)(4) would provide ambiguous
    definitions of the sanitation deficiencies used to identify and
    prioritize water and sewer projects in Indian country. As
    previously proposed ``deficiency level III'' could be
    interpreted to mean all methods of service delivery (including
    methods where water and sewer service is provided by hauling
    rather than through piping systems directly into the home) are
    adequate to meet the level III requirements and only the
    operating condition, such as frequent service interruptions,
    makes that facility deficient. This description assumes that
    water haul delivery systems and piped systems provide a similar
    level of service. We believe it is important to distinguish
    between the two.
        In addition, the definition for deficiency level V and
    deficiency level IV, though phrased differently, have
    essentially the same meaning. Level IV should refer to an
    individual home or community lacking either water or wastewater
    facilities, whereas, level V should refer to an individual home
    or community lacking both water and wastewater facilities.
        We recommend retaining current law to distinguish the
    various levels of deficiencies which determine the allocation
    of existing resources.

                threshold criteria for small ambulatory program

        Yet another Section 305(b)(1) would amend current law to
    set two minimum thresholds for the Small Ambulatory Program--
    one for number of patient visits and another for the number of
    eligible Indians. In order to be eligible for the Small
    Ambulatory Program under the previously proposed criteria, a
    facility must provide at least 150 patient visits annually in a
    service area with no fewer than 1,500 eligible Indians. Aside
    from the fact that these are both minimum thresholds and so
    somewhat contradictory, the proposed provisions would make
    implementation difficult. First, the IHS cannot validate
    patient visits unless the applicant participates in the
    Resource Patient Management System (RPMS). Since some tribes do
    not participate in the RPMS, it is difficult to ensure a fair
    evaluation of all applicants. Second, the term ``eligible
    Indians'' refers to the census population figures, which cannot
    be verified, since they are based on the individual's statement
    regarding ethnicity.

            new negotiated rulemaking and consultation requirements

        In addition, we are concerned about the requirements for
    negotiated rulemaking and increased requirements for
    consultation in the bill because of the high cost and staff
    time associated with this approach. We are committed to our on-
    going consultation with Tribes under current Executive Orders,
    as well as using the authority of Chapter V of title 5, United
    States Code (commonly known as the Administrative Procedures
    Act) to promulgate regulations where necessary to carry out
    IHCIA.
        The comments expressed today in this testimony do not
    represent a comprehensive list of our current concerns. And, we
    will be reviewing legislation introduced in this Congress for
    any provisions that might be addressed in the future.
        I reiterate our commitment to working with you to
    reauthorize the Indian Health Care Improvement Act, and the
    strengthening of Indian health care programs. And we will
    continue to work with the Committee, other Committees of
    Congress, and representatives of Indian country to develop a
    bill that all stakeholders in these important programs can
    support. Again, I appreciate the opportunity to appear before
    you today to discuss reauthorization of the ``Indian Health
    Care Improvement Act'' and I will answer any questions that you
    may have at this time. Thank you.

                                 Cost Estimates

        The Congressional Budget Office prepared a cost estimate
    for S. 1200, dated June 8, 2007. However, an error was made in
    that estimate, so a revised estimate was sent to the Committee
    on September 11, 2007, which follows.

    S. 1200--Indian Health Care Improvement Act Amendments of 2007

        Summary: S. 1200 would authorize the appropriation of such
    sums as are necessary through 2017 for activities under 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. Enacting the bill also would
    affect direct spending, primarily through provisions affecting
    the Medicaid program.
        CBO estimates that implementing S. 1200 would have
    discretionary costs of $2.7 billion in 2008, about $16 billion
    over the 2008-2012 period, and about $35 billion over the 2008-
    2017 period, assuming appropriation of the necessary amounts.
    We also estimate that enacting the bill would increase direct
    spending by $9 million in 2008, $53 million over the 2008-2012
    period, and $129 million over the 2008-2017 period.
        S. 1200 would preempt state licensing laws in certain
    cases, and this preemption would be an intergovernmental
    mandate as defined in the Unfunded Mandates Reform Act (UMRA);
    however, CBO estimates that the costs of that mandate would be
    small and would not approach the threshold established in UMRA
    ($66 million in 2007, adjusted annually for inflation). The
    bill also would place new requirements on Medicaid that would
    result in additional spending of about $80 million over the
    2008-2017 period. Those requirements, however, would not be
    intergovernmental mandates as defined by UMRA. Other provisions
    of the bill would benefit tribal governments by establishing
    new or expanding existing programs for Indian health care. This
    bill contains no private-sector mandates as defined in UMRA.
        Estimated cost to the Federal Government: The estimated
    budgetary impact of S. 1200 is summarized in Table 1. The costs
    of this legislation fall within budget function 550 (health).

                                    TABLE 1.--ESTIMATED BUDGETARY EFFECTS OF S. 1200
    ----------------------------------------------------------------------------------------------------------------
                                                                           By fiscal year, in millions of dollars--
                                                                        --------------------------------------------
                                                                           2008     2009     2010     2011     2012
    ----------------------------------------------------------------------------------------------------------------
                                      CHANGES IN SPENDING SUBJECT TO APPROPRIATION

    Estimated Authorization Level......................................    3,257    3,326    3,402    3,481    3,558
    Estimated Outlays..................................................    2,682    3,141    3,310    3,449    3,534

                                               CHANGES IN DIRECT SPENDINGa

    Estmated Budget Authority..........................................        9       10       11       12       12
    Estimated Outlays..................................................        9       10       11       12       12
    ----------------------------------------------------------------------------------------------------------------
    aDirect spending changes through 2017 are shown in Table 3.

        Basis of estimate: For the purpose of this estimate, CBO
    assumes that S. 1200 will be enacted near the start of fiscal
    year 2008 and that the necessary amounts will be appropriated
    for each year.

    Spending subject to appropriation

        The estimated effects of S. 1200 on spending subject to
    appropriation for the next five years are detailed in Table 2.
    Implementing the legislation would result in discretionary
    costs of about $16 billion over the 2008-2012 period. Because
    the bill would authorize funding through 2017, such
    discretionary cost would continue, with an estimated cost of
    about $35 billion over the 2008-2017 period.

                            TABLE 2.--ESTIMATED EFFECTS OF S. 1200 ON DISCRETIONARY SPENDING
    ----------------------------------------------------------------------------------------------------------------
                                                                      By fiscal year, in millions of dollars--
                                                               -----------------------------------------------------
                                                                  2007     2008     2009     2010     2011     2012
    ----------------------------------------------------------------------------------------------------------------
                                            SPENDING SUBJECT TO APPROPRIATION

    IHS Spending Under Current Lawa
        Budget Authority......................................    3,169        0        0        0        0        0
        Estimated Outlays.....................................    3,203      553      164       72       12        2
    Proposed Changes:
        Existing Indian Health Service Activities:
            Estimated Authorization Level.....................        0    3,247    3,320    3,396    3,475    3,554
            Estimated Outlays.................................        0    2,679    3,134    3,303    3,443    3,529
        Recruitment Program for Behavioral Health Careers:
            Authorization Level...............................        0        3        3        3        3        3
            Estimated Outlays.................................        0        2        3        3        3        3
        Mental Health Demonstration Project:
            Authorization Level...............................        0        2        2        2        2        0
            Estimated Outlays.................................        0        *        1        2        2        1
        Commission on Indian Health Care:
            Authorization Level...............................        0        4        0        0        0        0
            Estimated Outlays.................................        0        1        2        1        0        0
        Native American Health and Wellness Foundation:
            Authorization Level...............................        0        1        1        1        1        1
            Estimated Outlays.................................        0        *        1        1        1        1
            Total Changes:
                Estimated Authorization Level.................        0    3,257    3,326    3,402    3,481    3,558
                Estimated Outlays.............................        0    2,682    3,141    3,310    3,449    3,534
    Spending Under S. 1200
        Estimated Authorization Levela........................    3,169    3,257    3,326    3,402    3,481    3,558
        Estimated Outlays.....................................    3,203    3,235    3,305    3,382    3,461   3,536
    ----------------------------------------------------------------------------------------------------------------
    a.The 2007 level is the amount appropriated for that year for IHS.

    *Note: *=less than $500,000.

        Existing Indian Health Service Activities. S. 1200 would
    authorize the appropriation of such sums as are necessary for
    the Indian Health Service through 2017. The agency's
    responsibilities under the bill would be broadly similar to
    those in current law. In 2007, the agency received an
    appropriation of $3.2 billion. CBO's estimate of the authorized
    level for IHS programs is the appropriated amount for 2007
    adjusted for inflation in later years. (That level would grow
    to nearly $4 billion by 2017.) The estimated outlays reflect
    historical spending patterns for IHS activities.
        Recruitment Program for Behavioral Health Careers. Section
    105 of the bill would authorize the appropriation of $2.7
    million annually through 2017 for grants to develop and
    maintain programs that encourage Indians to pursue careers in a
    field related to behavioral health. Assuming the appropriation
    of the authorized amounts, CBO estimates that implementing this
    provision would cost $2 million in 2008, $13 million over the
    2008-2012 period, and $26 million over the 2008-2017 period.
        Mental Health Demonstration Project. Section 708 would
    authorize the appropriation of $1.5 million annually for fiscal
    years 2008 through 2011 for grants to examine the feasibility
    of using telecommunication technology to provide suicide
    prevention services to Indians. Assuming the appropriation of
    the authorized amounts, CBO estimates that implementing this
    provision would cost less than $500,000 in 2008 and about $6
    million over the 2008-2012 period.
        Commission on Indian Health Care. Section 814 would
    authorize the appropriation of $4 million for a commission that
    would examine how the federal government provides health care
    services to Indians. The members of the commission would have
    to be appointed within eight months of the bill's enactment and
    would be required to submit a final report to the Congress no
    later than 18 months after that. Assuming the appropriation of
    the authorized amount, CBO estimates that implementing this
    provision would cost $1 million in 2008, $2 million in 2009,
    and $1 million in 2010.
        Native American Health and Wellness Foundation. S. 1200
    would establish a charitable and nonprofit corporation called
    the Native American Health and Wellness Foundation to assist
    federal, state, tribal, and other entities in efforts to
    further health and wellness activities and opportunities for
    Indians. The bill would authorize the appropriation of $500,000
    annually for the foundation's administrative expenses; this
    amount would be adjusted in later years for inflation. Assuming
    the appropriation of the authorized amounts, CBO estimates that
    implementing this provision would cost less than $500,000 in
    2008 and about $2 million over the 2008-2012 period.

    Direct spending

        S. 1200 contains several provisions, primarily related to
    the Medicaid program, that would affect direct spending. The
    bill's estimated effects on direct spending are shown in Table
    3. Overall, CBO estimates that enacting the bill would increase
    direct spending by $9 million in 2008 and $129 million over the
    2008-2017 period.

                                                    TABLE 3.--ESTIMATED EFFECTS OF S. 1200 ON DIRECT SPENDING
    --------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                      By fiscal year, in millions of dollars--
                                                       -----------------------------------------------------------------------------------------------------
                                                         2008    2009    201O    2011    2012    2013    2014    2015    2016    2017   2008-2012  2008-2017
    --------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                   CHANGES IN DIRECT SPENDING

    Exemption from Medicaid Cost Sharing and Premiums:
        Estimated Budget Authority....................       5       6       6       7       7       8       8       9       9      10        31         74
        Estimated Outlays.............................       5       6       6       7       7       8       8       9       9      10        31         74
    Consultation with Indian Health Programs:
        Estimated Budget Authority....................       *       *       1       1       1       1       1       1       1       1         3          7
        Estimated Outlays.............................       *       *       1       1       1       1       1       1       1       1         3          7
    Medicaid Managed Care Provisions:
        Estimated Budget Authority....................       3       3       4       4       4       5       5       5       6       6        18         45
        Estimated Outlays.............................       3       3       4       4       4       5       5       5       6       6        18         45
    Scholarship and Loan Repayment Recovery Fund:
        Estimated Budget Authority....................       *       *       *       *       *       *       *       *       *       *         2          4
        Estimated Outlays.............................       *       *       *       *       *       *       *       *       *       *         2          4
    Total Changes:
        Estimated Budget Authority....................       9      10      11      12      12      14      14      15      16      17        53        129
        Estimated Outlays.............................       9      10      11      12      12      14      14      15      16      17        53        129
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    * = costs savings of less than $500,000.

    Notes: Components may not sum to totals because of rounding.

        IHS-funded health programs 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.
        Exemption from Medicaid Cost Sharing and Premiums. Section
    204 would prohibit Medicaid programs from charging premiums or
    other cost-sharing payments 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.
        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 280,000 Indians are Medicaid recipients who also use IHS,
    and that federal Medicaid spending on affected services would
    be about $225 per person annually in 2008. 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 payments by individuals equal 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 2008 and by $74 million over the 2008-2017 period.
        Consultation with Indian Health Programs. Section 206 would
    encourage state Medicaid programs to consult regularly with
    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 2008 and by $7 million over the 2008-2017 period.
        Medicaid Managed Care Provisions. Section 208 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 non-
    preferred 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 $3 million in 2008 and $45 million over the 2008-
    2017 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.
        Scholarship and Loan Repayment Recovery Fund. S. 1200 would
    allow the Secretary of Health and Human Services to spend
    amounts collected for breach of contract from recipients of
    certain IHS scholarships. Under current law, those funds are
    deposited in the Treasury and not spent. Because the
    Secretary's ability to spend those funds would not be subject
    to appropriation, the provision would increase direct spending.
    Based on historical information from IHS, CBO estimates that
    the provision would increase spending by less than $500,000 a
    year, but would total about $4 million over the 2008-2017
    period.
        Estimated impact on state, local, and tribal governments:

    Intergovernmental mandates

        S. 1200 would preempt state licensing laws in cases where a
    health care professional is licensed in one state but is
    performing services in another state under a contract or
    compact with a tribal health program. This preemption would be
    an intergovernmental mandate as defined in the UMRA; however,
    CBO estimates that the loss of any licensing fees resulting
    from the mandate would be small and would not approach the
    threshold established in UMRA ($66 million in 2007, adjusted
    annually for inflation).

    Other impacts

        S. 1200 would reauthorize and expand grant and assistance
    programs available to Indian tribes, tribal organizations, and
    urban Indian organizations for a range of health care programs,
    including prevention, treatment, and ongoing care. The bill
    also would allow IHS and tribal entities to share facilities,
    and it would authorize joint ventures between IHS and Indian
    tribes or tribal organizations for the construction and
    operation of health facilities. The bill would authorize
    funding for a variety of health services including hospice
    care, long-term care, public health services, and home and
    community-based services.
        The bill would prohibit states from charging cost sharing
    or premiums in the Medicaid program to Indians who receive
    services or benefits through an Indian health program. CBO
    estimates that the new requirements in the bill would result in
    additional spending by states of about $80 million over the
    2008-2017 period. Those requirements, however, would not be
    intergovernmental mandates as defined by UMRA because Medicaid
    provides states with significant flexibility to make
    programmatic adjustments to accommodate the changes. Some
    tribal entities, particularly those operating managed care
    systems, may realize some savings as a result of these
    provisions.
        Estimated impact on the private sector: This bill contains
    no private-sector mandates as defined in UMRA.
        Previous CBO estimate: This estimate supersedes the cost
    estimate for S. 1200 that CBO transmitted on June 8, 2007. Our
    June 8 cost estimate erroneously indicated that section 204 of
    the bill (exempting Indians from paying certain types of cost
    sharing and premiums) would apply to both Medicaid and the
    State Children's Health Insurance Program. The provision would
    apply only to Medicaid, and we have lowered our estimate of the
    bill's impact on direct spending by $4 million over the 2008-
    2012 period and by $8 million over the 2008-2017 period as a
    result.
        On September 11, 2007, CBO also issued a revised estimate
    for H.R. 1328, the Indian Health Care Improvement Act
    Amendments of 2007, as ordered reported by the House Committee
    on Natural Resources on April 25, 2007. There are only minor
    differences between the two bills, and CBO's revised estimates
    for them are identical.
        Estimate prepared by: Federal Costs: Eric Rollins; Impact
    on State, Local, and Tribal Governments: Lisa Ramirez-Branum;
    Impact on the Private Sector: Paige Shevlin.
        Estimate approved by: Peter H. Fontaine, Assistant Director
    for Budget Analysis.

                            Changes in Existing Law

        In accordance with subsection 12 of rule XXVI of the
    Standing Rules of the Senate, changes in existing law made by
    the bill S. 1200, as ordered reported, are shown as follows
    (existing law proposed to be omitted is enclosed in black
    brackets, new language to be added in italic, existing law to
    which no change is proposed is shown in roman):

                          UNITED STATES CODE ANNOTATED

                               TITLE 25. INDIANS

                         CHAPTER 18--INDIAN HEALTH CARE

    [Sec. 1601. Congressional]
    S 1200 IS
    110th CONGRESS
    1st Session
    S. 1200
    To amend the Indian Health Care Improvement Act to revise and
    extend that Act.
    IN THE SENATE OF THE UNITED STATES
    April 24, 2007
    Mr. DORGAN (for himself, Mrs. Boxer, Mr. Reid, Ms. Cantwell,
    Mr. Johnson, Mr. Tester, Mr. Inouye, Mr. Domenici, Mr.
    Bingaman, Mr. Baucus, Ms. Klobuchar, Mr. Thomas, Mr. Obama, and
    Ms. Murkowski) introduced the following bill; which was read
    twice and referred to the Committee on Indian Affairs
    A BILL
    To amend the Indian Health Care Improvement Act to revise and
    extend that Act.
        Be it enacted by the Senate and House of Representatives of
    the United States of America in Congress assembled,

    SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

        (a) Short Title.--This Act may be cited as the ``Indian
    Health Care Improvement Act Amendments of 2007''.
        (b) Table of Contents.--The table of contents of this Act
    is as follows:

    Sec. 1. Short title; table of contents.

                       TITLE I--AMENDMENTS TO INDIAN LAWS

    Sec. 101. Indian Health Care Improvement Act amended.
    Sec. 102. Soboba sanitation facilities.
    Sec. 103. Native American Health and Wellness Foundation.

     TITLE II--IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER THE SOCIAL
                                  SECURITY ACT

    Sec. 201. Expansion of payments under Medicare, Medicaid, and SCHIP for
              all covered services furnished by Indian Health Programs.
    Sec. 202. Increased outreach to Indians under Medicaid and SCHIP and
              improved cooperation in the provision of items and services to
              Indians under Social Security Act health benefit programs.
    Sec. 203. Additional provisions to increase outreach to, and enrollment
              of, Indians in SCHIP and Medicaid.
    Sec. 204. Premiums and cost sharing protections under Medicaid,
              eligibility determinations under Medicaid and SCHIP, and
              protection of certain Indian property from Medicaid estate
              recovery.
    Sec. 205. Nondiscrimination in qualifications for payment for services
              under Federal health care programs.
    Sec. 206. Consultation on Medicaid, SCHIP, and other health care
              programs funded under the Social Security Act involving Indian
              Health Programs and Urban Indian Organizations.
    Sec. 207. Exclusion waiver authority for affected Indian Health Programs
              and safe harbor transactions under the Social Security Act.
    Sec. 208. Rules applicable under Medicaid and SCHIP to managed care
              entities with respect to Indian enrollees and Indian health
              care providers and Indian managed care entities.
    Sec. 209. Annual report on Indians served by Social Security Act health
              benefit programs.

                       TITLE I--AMENDMENTS TO INDIAN LAWS

    SEC. 101. INDIAN HEALTH CARE IMPROVEMENT ACT AMENDED.

        (a) In General.--The Indian Health Care Improvement Act (25
    U.S.C. 1601 et seq.) is amended to read as follows:

    SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

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

    Sec. 1. Short title; table of contents.
    Sec. 2. Findings.
    Sec. 3. Declaration of national Indian health policy.
    Sec. 4. Definitions.

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

    Sec. 101. Purpose.
    Sec. 102. Health professions recruitment program for Indians.
    Sec. 103. Health professions preparatory scholarship program for
              Indians.
    Sec. 104. Indian health professions scholarships.
    Sec. 105. American Indians Into Psychology Program.
    Sec. 106. Scholarship programs for Indian Tribes.
    Sec. 107. Indian Health Service extern programs.
    Sec. 108. Continuing education allowances.
    Sec. 109. Community Health Representative Program.
    Sec. 110. Indian Health Service Loan Repayment Program.
    Sec. 111. Scholarship and Loan Repayment Recovery Fund.
    Sec. 112. Recruitment activities.
    Sec. 113. Indian recruitment and retention program.
    Sec. 114. Advanced training and research.
    Sec. 115. Quentin N. Burdick American Indians Into Nursing Program.
    Sec. 116. Tribal cultural orientation.
    Sec. 117. INMED Program.
    Sec. 118. Health training programs of community colleges.
    Sec. 119. Retention bonus.
    Sec. 120. Nursing residency program.
    Sec. 121. Community Health Aide Program.
    Sec. 122. Tribal Health Program administration.
    Sec. 123. Health professional chronic shortage demonstration programs.
    Sec. 124. National Health Service Corps.
    Sec. 125. Substance abuse counselor educational curricula demonstration
              programs.
    Sec. 126. Behavioral health training and community education programs.
    Sec. 127. Authorization of appropriations.

                            TITLE II--HEALTH SERVICES

    Sec. 201. Indian Health Care Improvement Fund.
    Sec. 202. Catastrophic Health Emergency Fund.
    Sec. 203. Health promotion and disease prevention services.
    Sec. 204. Diabetes prevention, treatment, and control.
    Sec. 205. Shared services for long-term care.
    Sec. 206. Health services research.
    Sec. 207. Mammography and other cancer screening.
    Sec. 208. Patient travel costs.
    Sec. 209. Epidemiology centers.
    Sec. 210. Comprehensive school health education programs.
    Sec. 211. Indian youth program.
    Sec. 212. Prevention, control, and elimination of communicable and
              infectious diseases.
    Sec. 213. Other authority for provision of services.
    Sec. 214. Indian women's health care.
    Sec. 215. Environmental and nuclear health hazards.
    Sec. 216. Arizona as a contract health service delivery area.
    Sec. 216A. North Dakota and South Dakota as contract health service
              delivery area.
    Sec. 217. California contract health services program.
    Sec. 218. California as a contract health service delivery area.
    Sec. 219. Contract health services for the Trenton service area.
    Sec. 220. Programs operated by Indian Tribes and Tribal Organizations.
    Sec. 221. Licensing.
    Sec. 222. Notification of provision of emergency contract health
              services.
    Sec. 223. Prompt action on payment of claims.
    Sec. 224. Liability for payment.
    Sec. 225. Office of Indian Men's Health.
    Sec. 226. Authorization of appropriations.

                              TITLE III--FACILITIES

    Sec. 301. Consultation; construction and renovation of facilities;
              reports.
    Sec. 302. Sanitation facilities.
    Sec. 303. Preference to Indians and Indian firms.
    Sec. 304. Expenditure of non-Service funds for renovation.
    Sec. 305. Funding for the construction, expansion, and modernization of
              small ambulatory care facilities.
    Sec. 306. Indian health care delivery demonstration projects.
    Sec. 307. Land transfer.
    Sec. 308. Leases, contracts, and other agreements.
    Sec. 309. Study on loans, loan guarantees, and loan repayment.
    Sec. 310. Tribal leasing.
    Sec. 311. Indian Health Service/tribal facilities joint venture program.
    Sec. 312. Location of facilities.
    Sec. 313. Maintenance and improvement of health care facilities.
    Sec. 314. Tribal management of Federally-owned quarters.
    Sec. 315. Applicability of Buy American Act requirement.
    Sec. 316. Other funding for facilities.
    Sec. 317. Authorization of appropriations.

                       TITLE IV--ACCESS TO HEALTH SERVICES

    Sec. 401. Treatment of payments under Social Security Act health
              benefits programs.
    Sec. 402. Grants to and contracts with the Service, Indian Tribes,
              Tribal Organizations, and Urban Indian Organizations to
              facilitate outreach, enrollment, and coverage of Indians under
              Social Security Act health benefit programs and other health
              benefits programs.
    Sec. 403. Reimbursement from certain third parties of costs of health
              services.
    Sec. 404. Crediting of reimbursements.
    Sec. 405. Purchasing health care coverage.
    Sec. 406. Sharing arrangements with Federal agencies.
    Sec. 407. Payor of last resort.
    Sec. 408. Nondiscrimination under Federal health care programs in
              qualifications for reimbursement for services.
    Sec. 409. Consultation.
    Sec. 410. State Children's Health Insurance Program (SCHIP).
    Sec. 411. Exclusion waiver authority for affected Indian Health Programs
              and safe harbor transactions under the Social Security Act.
    Sec. 412. Premium and cost sharing protections and eligibility
              determinations under Medicaid and SCHIP and protection of
              certain Indian property from Medicaid estate recovery.
    Sec. 413. Treatment under Medicaid and SCHIP managed care.
    Sec. 414. Navajo Nation Medicaid Agency feasibility study.
    Sec. 415. General exceptions.
    Sec. 416. Authorization of appropriations.

                   TITLE V--HEALTH SERVICES FOR URBAN INDIANS

    Sec. 501. Purpose.
    Sec. 502. Contracts with, and grants to, Urban Indian Organizations.
    Sec. 503. Contracts and grants for the provision of health care and
              referral services.
    Sec. 504. Contracts and grants for the determination of unmet health
              care needs.
    Sec. 505. Evaluations; renewals.
    Sec. 506. Other contract and grant requirements.
    Sec. 507. Reports and records.
    Sec. 508. Limitation on contract authority.
    Sec. 509. Facilities.
    Sec. 510. Division of Urban Indian Health.
    Sec. 511. Grants for alcohol and substance abuse-related services.
    Sec. 512. Treatment of certain demonstration projects.
    Sec. 513. Urban NIAAA transferred programs.
    Sec. 514. Consultation with Urban Indian Organizations.
    Sec. 515. Urban youth treatment center demonstration.
    Sec. 516. Grants for diabetes prevention, treatment, and control.
    Sec. 517. Community Health Representatives.
    Sec. 518. Effective date.
    Sec. 519. Eligibility for services.
    Sec. 520. Authorization of appropriations.

                      TITLE VI--ORGANIZATIONAL IMPROVEMENTS

    Sec. 601. Establishment of the Indian Health Service as an agency of the
              Public Health Service.
    Sec. 602. Automated management information system.
    Sec. 603. Authorization of appropriations.

                      TITLE VII--BEHAVIORAL HEALTH PROGRAMS

    Sec. 701. Behavioral health prevention and treatment services.
    Sec. 702. Memoranda of agreement with the Department of the Interior.
    Sec. 703. Comprehensive behavioral health prevention and treatment
              program.
    Sec. 704. Mental health technician program.
    Sec. 705. Licensing requirement for mental health care workers.
    Sec. 706. Indian women treatment programs.
    Sec. 707. Indian youth program.
    Sec. 708. Indian youth telemental health demonstration project.
    Sec. 709. Inpatient and community-based mental health facilities design,
              construction, and staffing.
    Sec. 710. Training and community education.
    Sec. 711. Behavioral health program.
    Sec. 712. Fetal alcohol disorder programs.
    Sec. 713. Child sexual abuse and prevention treatment programs.
    Sec. 714. Behavioral health research.
    Sec. 715. Definitions.
    Sec. 716. Authorization of appropriations.

                            TITLE VIII--MISCELLANEOUS

    Sec. 801. Reports.
    Sec. 802. Regulations.
    Sec. 803. Plan of implementation.
    Sec. 804. Availability of funds.
    Sec. 805. Limitation on use of funds appropriated to Indian Health
              Service.
    Sec. 806. Eligibility of California Indians.
    Sec. 807. Health services for ineligible persons.
    Sec. 808. Reallocation of base resources.
    Sec. 809. Results of demonstration projects.
    Sec. 810. Provision of services in Montana.
    Sec. 811. Moratorium.
    Sec. 812. Tribal employment.
    Sec. 813. Severability provisions.
    Sec. 814. Establishment of National Bipartisan Commission on Indian
              Health Care.
    Sec. 815. Confidentiality of medical quality assurance records;
              qualified immunity for participants.
    Sec. 816. Appropriations; availability.
    Sec. 817. Authorization of appropriations.

    SEC. 2. FINDINGS.

        Congress makes the following findings:
        [The Congress finds the following:
              [(a] (1) Federal health services to maintain and
            improve the health of the Indians are consonant with
            and required by the Federal Government's historical and
            unique legal relationship with, and resulting
            responsibility to, the American Indian people.
              [(b] (2) A major national goal of the United States
            is to provide the quantity and quality of health
            services which will permit the health status of Indians
            to be raised to the highest possible level and to
            encourage the maximum participation of Indians in the
            planning and management of those services.
              [(c] (3) Federal health services to Indians have
            resulted in a reduction in the prevalence and incidence
            of preventable illnesses among, and unnecessary and
            premature deaths of, Indians.
              [(d] (4) Despite such services, the unmet health
            needs of the American Indian people are severe and the
            health status of the Indians is far below that of the
            general population of the United States.

    [Sec. 1602. Declaration of health objectives]

    SEC. 3. DECLARATION OF NATIONAL INDIAN HEALTH POLICY.

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

    [Sec. 1603. Definitions]

              (6) to provide funding for programs and facilities
            operated by Indian Tribes and Tribal Organizations in
            amounts that are not less than the amounts provided to
            programs and facilities operated directly by the
            Service.

    SEC. 4. DEFINITIONS.

        For purposes of this [chapter--]Act:
              (1) The term ``accredited and accessible'' means on
            or near a reservation and accredited by a national or
            regional organization with accrediting authority.
              (2) The term ``Area Office'' means an administrative
            entity, including a program office, within the Service
            through which services and funds are provided to the
            Service Units within a defined geographic area.
              (3) The term ``Assistant Secretary'' means the
            Assistant Secretary for Indian Health.
              (4)(A) The term ``behavioral health'' means the
            blending of substance (alcohol, drugs, inhalants, and
            tobacco) abuse and mental health prevention and
            treatment, for the purpose of providing comprehensive
            services.
              (B) The term ``behavioral health'' includes the joint
            development of substance abuse and mental health
            treatment planning and coordinated case management
            using a multidisciplinary approach.
              (5) The term ``California Indians'' means those
            Indians who are eligible for health services of the
            Service pursuant to section 806.
              (6) The term ``community college'' means--
                      (A) a tribal college or university, or
                      (B) a junior or community college.
              (7) The term ``contract health service'' means health
            services provided at the expense of the Service or a
            Tribal Health Program by public or private medical
            providers or hospitals, other than the Service Unit or
            the Tribal Health Program at whose expense the services
            are provided.
              [(a) ``Secretary''] (8) The term ``Department''
            means, unless otherwise designated, [means the
            Secretary]the Department of Health and Human Services.
        [(b) ``Service'' means the Indian Health Service.]
              (9) The term ``disease prevention'' means the
            reduction, limitation, and prevention of disease and
            its complications and reduction in the consequences of
            disease, including--
                      (A) controlling--
                              (i) the development of diabetes;
                              (ii) high blood pressure;
                              (iii) infectious agents;
                              (iv) injuries;
                              (v) occupational hazards and
                            disabilities;
                              (vi) sexually transmittable diseases;
                            and
                              (vii) toxic agents; and
                      (B) providing--
                              (i) fluoridation of water; and
                              (ii) immunizations.
              (10) The term ``health profession'' means allopathic
            medicine, family medicine, internal medicine,
            pediatrics, geriatric medicine, obstetrics and
            gynecology, podiatric medicine, nursing, public health
            nursing, dentistry, psychiatry, osteopathy, optometry,
            pharmacy, psychology, public health, social work,
            marriage and family therapy, chiropractic medicine,
            environmental health and engineering, allied health
            professions, and any other health profession.
              (11) The term ``health promotion'' means--
                      (A) fostering social, economic,
                    environmental, and personal factors conducive
                    to health, including raising public awareness
                    about health matters and enabling the people to
                    cope with health problems by increasing their
                    knowledge and providing them with valid
                    information;
                      (B) encouraging adequate and appropriate
                    diet, exercise, and sleep;
                      (C) promoting education and work in
                    conformity with physical and mental capacity;
                      (D) making available safe water and sanitary
                    facilities;
                      (E) improving the physical, economic,
                    cultural, psychological, and social
                    environment;
                      (F) promoting culturally competent care; and
                      (G) providing adequate and appropriate
                    programs, which may include--
                              (i) abuse prevention (mental and
                            physical);
                              (ii) community health;
                              (iii) community safety;
                              (iv) consumer health education;
                              (v) diet and nutrition;
                              (vi) immunization and other
                            prevention of communicable diseases,
                            including HIV/AIDS;
                              (vii) environmental health;
                              (viii) exercise and physical fitness;
                              (ix) avoidance of fetal alcohol
                            disorders;
                              (x) first aid and CPR education;
                              (xi) human growth and development;
                              (xii) injury prevention and personal
                            safety;
                              (xiii) behavioral health;
                              (xiv) monitoring of disease
                            indicators between health care provider
                            visits, through appropriate means,
                            including Internet-based health care
                            management systems;
                              (xv) personal health and wellness
                            practices;
                              (xvi) personal capacity building;
                              (xvii) prenatal, pregnancy, and
                            infant care;
                              (xviii) psychological well-being;
                              (xix) reproductive health and family
                            planning;
                              (xx) safe and adequate water;
                              (xxi) healthy work environments;
                              (xxii) elimination, reduction, and
                            prevention of contaminants that create
                            unhealthy household conditions
                            (including mold and other allergens);
                              (xxiii) stress control;
                              (xxiv) substance abuse;
                              (xxv) sanitary facilities;
                              (xxvi) sudden infant death syndrome
                            prevention;
                              (xxvii) tobacco use cessation and
                            reduction;
                              (xxviii) violence prevention; and
                              (xxix) such other activities
                            identified by the Service, a Tribal
                            Health Program, or an Urban Indian
                            Organization, to promote achievement of
                            any of the objectives described in
                            section 3(2).
              [(c) ``Indians'' or] (12) The term ``Indian'', unless
            otherwise designated, means any person who is a member
            of an Indian [tribe, as defined in subsection (d) of
            this section,] Tribe or is eligible for health services
            under section 806, except that, for the purpose of
            sections [1612 and 1613 of this title, such terms shall
            mean] 102 and 103, the term also means any individual
            who [(1),]--
                      (A)(i) irrespective of whether [he or she]
                    the individual lives on or near a reservation,
                    is a member of a tribe, band, or other
                    organized group of Indians, including those
                    tribes, bands, or groups terminated since 1940
                    and those recognized now or in the future by
                    the State in which they reside[,]; or [who]
                      (ii) is a descendant, in the first or second
                    degree, of any such member[, or (2)];
                      (B) is an Eskimo or Aleut or other Alaska
                    Native[, or (3)];
                      (C) is considered by the Secretary of the
                    Interior to be an Indian for any purpose[, or
                    (4)]; or
                      (D) is determined to be an Indian under
                    regulations promulgated by the Secretary.
              (13) The term ``Indian Health Program'' means--
                      (A) any health program administered directly
                    by the Service;
                      (B) any Tribal Health Program; or
                      (C) any Indian Tribe or Tribal Organization
                    to which the Secretary provides funding
                    pursuant to section 23 of the Act of June 25,
                    1910 (25 U.S.C. 47) (commonly known as the
                    ``Buy Indian Act'').
              (14) The term ``Indian Tribe'' has the meaning given
            the term in the Indian Self-Determination and Education
            Assistance Act (25 U.S.C. 450 et seq.).
              (15) The term ``junior or community college'' has the
            meaning given the term by section 312(e) of the Higher
            Education Act of 1965 (20 U.S.C. 1058(e)).
              [(d) ``Indian tribe'' means any Indian tribe, band,
            nation, or other organized group or community,
            including any Alaska Native village or group or
            regional or village corporation as defined in or] (16)
            The term ``reservation'' means any federally recognized
            Indian Tribe's reservation, Pueblo, or colony,
            including former reservations in Oklahoma, Indian
            allotments, and Alaska Native Regions established
            pursuant to the Alaska Native Claims Settlement Act
            ([85 Stat. 688) []43 U.S.C.[A Sec. 1601 et seq.], which
            is recognized as eligible for the special programs and
            services provided by the United States to Indians
            because of their status as Indians.] 1601 et seq.).
        [(e) ``Tribal organization'' means the elected governing
    body of any Indian tribe or any legally established
    organization of Indians which is controlled by one or more such
    bodies or by a board of directors elected or selected by one or
    more such bodies (or elected by the Indian population to be
    served by such organization) and which includes the maximum
    participation of Indians in all phases of its activities.
        [(f) ``Urban Indian'' means any individual who resides in
    an urban center, as defined in subsection (g) hereof, and who
    meets one or more of the four criteria in subsection (c)(1)
    through (4) of this section.]
              (17) The term ``Secretary'', unless otherwise
            designated, means the Secretary of Health and Human
            Services.
              (18) The term ``Service'' means the Indian Health
            Service.
              (19) The term ``Service Area'' means the geographical
            area served by each Area Office.
              (20) The term ``Service Unit'' means an
            administrative entity of the Service, or a Tribal
            Health Program through which services are provided,
            directly or by contract, to eligible Indians within a
            defined geographic area.
              (21) The term ``telehealth'' has the meaning given
            the term in section 330K(a) of the Public Health
            Service Act (42 U.S.C. 254c-16(a)).
              (22) The term ``telemedicine'' means a
            telecommunications link to an end user through the use
            of eligible equipment that electronically links health
            professionals or patients and health professionals at
            separate sites in order to exchange health care
            information in audio, video, graphic, or other format
            for the purpose of providing improved health care
            services.
              (23) The term ``tribal college or university'' has
            the meaning given the term in section 316(b)(3) of the
            Higher Education Act (20 U.S.C. 1059c(b)(3)).
              (24) The term ``Tribal Health Program'' means an
            Indian Tribe or Tribal Organization that operates any
            health program, service, function, activity, or
            facility funded, in whole or part, by the Service
            through, or provided for in, a contract or compact with
            the Service under the Indian Self-Determination and
            Education Assistance Act (25 U.S.C. 450 et seq.).
              (25) The term ``Tribal Organization'' has the meaning
            given the term in the Indian Self-Determination and
            Education Assistance Act (25 U.S.C. 450 et seq.).
              [(g)] (26) [``]The term ``Urban [center''] Center''
            means any community which has a sufficient [urban]
            Urban Indian population with unmet health needs to
            warrant assistance under [subchapter IV] title V of
            this [chapter] Act, as determined by the Secretary.
              (27) The term ``Urban Indian'' means any individual
            who resides in an Urban Center and who meets 1 or more
            of the following criteria:
                      (A) Irrespective of whether the individual
                    lives on or near a reservation, the individual
                    is a member of a tribe, band, or other
                    organized group of Indians, including those
                    tribes, bands, or groups terminated since 1940
                    and those tribes, bands, or groups that are
                    recognized by the States in which they reside,
                    or who is a descendant in the first or second
                    degree of any such member.
                      (B) The individual is an Eskimo, Aleut, or
                    other Alaska Native.
                      (C) The individual is considered by the
                    Secretary of the Interior to be an Indian for
                    any purpose.
                      (D) The individual is determined to be an
                    Indian under regulations promulgated by the
                    Secretary.
              [(h)] (28) The term ``Urban Indian [organization'']
            Organization'' means a nonprofit corporate body that
            (A) is situated in an [urban center,] Urban Center; (B)
            is governed by an [urban] Urban Indian-controlled board
            of directors[, and providing]; (C) provides for the
            [maximum] participation of all interested Indian groups
            and individuals[, which body]; and (D) is capable of
            legally cooperating with other public and private
            entities for the purpose of performing the activities
            described in section [1653] 503(a).

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

    SEC. 101. PURPOSE.

        The purpose of this title[.]
        [(i) ``Area office'' means an administrative entity
    including a program office, within the Indian Health Service
    through which services and funds are provided to the service
    units within a defined geographic area.
        [(j) ``Service unit'' means--
              [(1) an administrative entity within the Indian
            Health Service, or
              [(2) a tribe or tribal organization operating health
            care programs or facilities with funds from the Service
            under the Indian Self-Determination Act [25 U.S.C.A.
            Sec. 450f et seq.], through which services are
            provided, directly or by contract, to the eligible
            Indian population within a defined geographic area.
        [(k) ``Health promotion'' includes--
              [(1) cessation of tobacco smoking,
              [(2) reduction in the misuse of alcohol and drugs,
              [(3) improvement of nutrition,
              [(4) improvement in physical fitness,
              [(5) family planning,
              [(6) control of stress, and
              [(7) pregnancy and infant care (including prevention
            of fetal alcohol syndrome).
        [(l) ``Disease prevention'' includes--
              [(1) immunizations,
              [(2) control of high blood pressure,
              [(3) control of sexually transmittable diseases,
              [(4) prevention and control of diabetes,
              [(5) control of toxic agents,
              [(6) occupational safety and health,
              [(7) accident prevention,
              [(8) fluoridation of water, and
              [(9) control of infectious agents.
        [(m) ``Service area'' means the geographical area served by
    each area office.
        [(n) ``Health profession'' means allopathic medicine,
    family medicine, internal medicine, pediatrics, geriatric
    medicine, obstetrics and gynecology, podiatric medicine,
    nursing, public health nursing, dentistry, psychiatry,
    osteopathy, optometry, pharmacy, psychology, public health,
    social work, marriage and family therapy, chiropractic
    medicine, environmental health and engineering, an allied
    health profession, or any other health profession.
        [(o) ``Substance abuse'' includes inhalant abuse.
        [(p) ``FAE'' means fetal alcohol effect.
        [(q) ``FAS'' means fetal alcohol syndrome.
        [Sec. 1611. Congressional statement of purpose The purpose
    of this subchapter] is to increase, to the maximum extent
    feasible, the number of Indians entering the health professions
    and providing health services, and to assure an [adequate]
    optimum supply of health professionals to the [Service, Indian
    tribes, tribal organizations, and urban Indian organizations]
    Indian Health Programs and Urban Indian Organizations involved
    in the provision of health [care] services to [Indian people]
    Indians.

    [Sec. 1612. Health professions recruitment program for Indians]

    SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM FOR INDIANS.

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

    [Sec. 1613. Health professions preparatory scholarship program for
                        Indians]

    SEC. 103. HEALTH PROFESSIONS PREPARATORY SCHOLARSHIP PROGRAM FOR
                        INDIANS.

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

    [Sec. 1613a. Indian health professions scholarships]

    SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS.

        [(a) General Authority] (a) In General.--
              [In order to provide health professionals to Indians,
            Indian tribes, tribal organizations, and urban Indian
            organizations, the] (1) Authority.--The Secretary,
            acting through the Service [and in accordance with this
            section], shall make scholarship grants to Indians who
            are enrolled full or part time in [appropriately]
            accredited schools [and] pursuing courses of study in
            the health professions. Such scholarships shall be
            designated Indian Health Scholarships and shall be made
            in accordance with section [254l of Title 42,] 338A of
            the Public Health Services Act (42 U.S.C. 254l), except
            as provided in subsection (b) of this section.
        [(b) Recipients; active duty service obligation]
              [(1)] (2) Determinations by secretary.--The
            Secretary, acting through the Service, shall
            determine--
                      (A) who shall receive [scholarships]
                    scholarship grants under subsection (a); and
                    [shall determine]
                      (B) the distribution of [such] the
                    scholarships among [such] health professions on
                    the basis of the relative needs of Indians for
                    additional service in [such] the health
                    professions. [(2) An individual shall be
                    eligible for a scholarship under subsection (a)
                    of this section in any year in which such
                    individual is enrolled full or part time in a
                    course of study referred to in subsection (a)
                    of this section.]
              (3) Certain delegation not allowed.--The
            administration of this section shall be a
            responsibility of the Assistant Secretary and shall not
            be delegated in a contract or compact under the Indian
            Self-Determination and Education Assistance Act (25
            U.S.C. 450 et seq.).
        (b) Active Duty Service Obligation_
              [(3)(A)] (1) Obligation met.--The active duty service
            obligation under a written contract with the Secretary
            under this section [254l of Title 42] that an
            [individual] Indian has entered into [under that
            section] shall, if that individual is a recipient of an
            Indian Health Scholarship, be met in full-time
            practice[, by service--] equal to 1 year for each
            school year for which the participant receives a
            scholarship award under this part, or 2 years,
            whichever is greater, by service in 1 or more of the
            following:
                      [(i) in the Indian Health Service;]
                      [(ii) in a program conducted under a contract
                    entered into under the Indian Self-
                    Determination Act [25 U.S.C.A. Sec. 450f et
                    seq.];]
                      (A) In an Indian Health Program.
                      [(iii)] (B) [in] In a program assisted under
                    [subchapter IV of this chapter;] title V of
                    this Act.
                      [(iv)] (C) [in]In the private practice of the
                    applicable profession if, as determined by the
                    Secretary, in accordance with guidelines
                    promulgated by the Secretary, such practice is
                    situated in a physician or other health
                    professional shortage area and addresses the
                    health care needs of a substantial number of
                    Indians[; or].
                      (D) In a teaching capacity in a tribal
                    college or university nursing program (or a
                    related health profession program) if, as
                    determined by the Secretary, the health service
                    provided to Indians would not decrease.
              [(B)] (2) Obligation deferred.--At the request of any
            individual who has entered into a contract referred to
            in [subparagraph (A]paragraph (1) and who receives a
            degree in medicine (including osteopathic or allopathic
            medicine), dentistry, optometry, podiatry, or pharmacy,
            the Secretary shall defer the active duty service
            obligation of that individual under that contract, in
            order that such individual may complete any internship,
            residency, or other advanced clinical training that is
            required for the practice of that health profession,
            for an appropriate period (in years, as determined by
            the Secretary), subject to the following conditions:
                      [(i)] (A) No period of internship, residency,
                    or other advanced clinical training shall be
                    counted as satisfying any period of obligated
                    service [that is required] under this
                    [section]subsection.
                      [(ii)] (B) The active duty service obligation
                    of that individual shall commence not later
                    than 90 days after the completion of that
                    advanced clinical training (or by a date
                    specified by the Secretary).
                      [(iii)] (C) The active duty service
                    obligation will be served in the health
                    profession of that individual, in a manner
                    consistent with [clauses (i) through (v) of
                    subparagraph (A)] paragraph (1).
                      [(C)] (D) A recipient of [an Indian Health
                    Scholarship]a scholarship under this section
                    may, at the election of the recipient, meet the
                    active duty service obligation described in
                    [subparagraph (A)] paragraph (1) by service in
                    a program specified [in] under that
                    [subparagraph] paragraph that--
                              (i) is located on the reservation of
                            the [tribe] Indian Tribe in which the
                            recipient is enrolled; or
                              (ii) serves the [tribe] Indian Tribe
                            in which the recipient is enrolled.
              [(D)] (3) Priority when making assignments.--Subject
            to [subparagraph (C] paragraph (2), the Secretary, in
            making assignments of Indian Health Scholarship
            recipients required to meet the active duty service
            obligation described in [subparagraph (A)] paragraph
            (1), shall give priority to assigning individuals to
            service in those programs specified in [subparagraph
            (A)] paragraph (1) that have a need for health
            professionals to provide health care services as a
            result of individuals having breached contracts entered
            into under this section.
        [(4)] (c) Part-Time Students.--In the case of an individual
    receiving a scholarship under this section who is enrolled part
    time in an approved course of study--
              [(A)] (1) such scholarship shall be for a period of
            years not to exceed the part-time equivalent of 4
            years, as determined by the Secretary;
              [(B)] (2) the period of obligated service described
            in [paragraph (3)(A)] subsection (b)(1) shall be equal
            to the greater of--
                      [(i)] (A) the part-time equivalent of [one] 1
                    year for each year for which the individual was
                    provided a scholarship (as determined by the
                    Secretary); or
                      [(ii)] (B) [two] 2 years; and
              [(C)] (3) the amount of the monthly stipend specified
            in section 338A(g)(1)(B) of the Public Health Service
            Act (42 U.S.C. 254l(g)(1)(B) [of Title 42]) shall be
            reduced pro rata (as determined by the Secretary) based
            on the number of hours such student is enrolled.
              [(5)(A) An individual who has, on or after October
            29, 1992, entered into a written contract with the
            Secretary under this section and who--]
          (d) Breach of Contract.--
              (1) Specified breaches.--An individual shall be
            liable to the United States for the amount which has
            been paid to the individual, or on behalf of the
            individual, under a contract entered into with the
            Secretary under this section on or after the date of
            enactment of the Indian Health Care Improvement Act
            Amendments of 2007 if that individual--
                      [(i)] (A) fails to maintain an acceptable
                    level of academic standing in the educational
                    institution in which he or she is enrolled
                    (such level determined by the educational
                    institution under regulations of the
                    Secretary)[,];
                      [(ii)] (B) is dismissed from such educational
                    institution for disciplinary reasons[,];
                      [(iii)] (C) voluntarily terminates the
                    training in such an educational institution for
                    which he or she is provided a scholarship under
                    such contract before the completion of such
                    training[,]; or
                      [(iv)] (D) fails to accept payment, or
                    instructs the educational institution in which
                    he or she is enrolled not to accept payment, in
                    whole or in part, of a scholarship under such
                    contract, in lieu of any service obligation
                    arising under such contract[, shall be liable
                    to the United States for the amount which has
                    been paid to him, or on his behalf, under the
                    contract].
              [(B)] (2) Other breaches.--If for any reason not
            specified in [subparagraph (A)] paragraph (1) an
            individual breaches [his] a written contract by failing
            either to begin such individual's service obligation
            required under [this section] such contract or to
            complete such service obligation, the United States
            shall be entitled to recover from the individual an
            amount determined in accordance with the formula
            specified in subsection (l) of section [1616a(l) of
            this title] 110 in the manner provided for in such
            subsection.
              [(C)] (3) Cancellation upon death of recipient.--Upon
            the death of an individual who receives an Indian
            Health Scholarship, any outstanding obligation of that
            individual for service or payment that relates to that
            scholarship shall be canceled.
              (4) Waivers and suspensions.--
                      [(D)] (A) In general.--The Secretary shall
                    provide for the partial or total waiver or
                    suspension of any obligation of service or
                    payment of a recipient of an Indian Health
                    Scholarship if the Secretary determines that--
                              (i) it is not possible for the
                            recipient to meet that obligation or
                            make that payment;
                              (ii) requiring that recipient to meet
                            that obligation or make that payment
                            would result in extreme hardship to the
                            recipient; or
                              (iii) the enforcement of the
                            requirement to meet the obligation or
                            make the payment would be
                            unconscionable.
                      (B) Factors for consideration.--Before
                    waiving or suspending an obligation of service
                    or payment under subparagraph (A), the
                    Secretary shall consult with the affected Area
                    Office, Indian Tribes, Tribal Organizations, or
                    Urban Indian Organizations, and may take into
                    consideration whether the obligation may be
                    satisfied in a teaching capacity at a tribal
                    college or university nursing program under
                    subsection (b)(1)(D).
              [(E)] (5) Extreme hardship.--Notwithstanding any
            other provision of law, in any case of extreme hardship
            or for other good cause shown, the Secretary may waive,
            in whole or in part, the right of the United States to
            recover funds made available under this section.
              [(F)] (6) Bankruptcy.--Notwithstanding any other
            provision of law, with respect to a recipient of an
            Indian Health Scholarship, no obligation for payment
            may be released by a discharge in bankruptcy under
            [Title] title 11, United States Code, unless that
            discharge is granted after the expiration of the 5-year
            period beginning on the initial date on which that
            payment is due, and only if the bankruptcy court finds
            that the nondischarge of the obligation would be
            unconscionable.
        [(c) Placement Office]

    SEC. 105. AMERICAN INDIANS INTO PSYCHOLOGY PROGRAM.

        (a) Grants Authorized.--The Secretary, acting through the
    Service, shall make grants of not more than $300,000 to each of
    9 colleges and universities for the purpose of developing and
    maintaining Indian psychology career recruitment programs as a
    means of encouraging Indians to enter the behavioral health
    field. These programs shall be located at various locations
    throughout the country to maximize their availability to Indian
    students and new programs shall be established in different
    locations from time to time.
        (b) Quentin N. Burdick Program Grant.--The Secretary shall
    provide a grant authorized under subsection (a) to develop and
    maintain a program at the University of North Dakota to be
    known as the `Quentin N. Burdick American Indians Into
    Psychology Program'. Such program shall, to the maximum extent
    feasible, coordinate with the Quentin N. Burdick Indian Health
    Programs authorized under section 117(b), the Quentin N.
    Burdick American Indians Into Nursing Program authorized under
    section 115(e), and existing university research and
    communications networks.
        (c) Regulations.--The Secretary shall issue regulations
    pursuant to this Act for the competitive awarding of grants
    provided under this section.
        (d) Conditions of Grant.--Applicants under this section
    shall agree to provide a program which, at a minimum--
              (1) provides outreach and recruitment for health
            professions to Indian communities including elementary,
            secondary, and accredited and accessible community
            colleges that will be served by the program;
              (2) incorporates a program advisory board comprised
            of representatives from the tribes and communities that
            will be served by the program;
              (3) provides summer enrichment programs to expose
            Indian students to the various fields of psychology
            through research, clinical, and experimental
            activities;
              (4) provides stipends to undergraduate and graduate
            students to pursue a career in psychology;
              (5) develops affiliation agreements with tribal
            colleges and universities, the Service, university
            affiliated programs, and other appropriate accredited
            and accessible entities to enhance the education of
            Indian students;
              (6) to the maximum extent feasible, uses existing
            university tutoring, counseling, and student support
            services; and
              (7) to the maximum extent feasible, employs qualified
            Indians in the program.
        [The Secretary shall, acting through the Service, establish
    a Placement Office to develop and implement a national policy
    for the placement, to available vacancies within the Service,
    of Indian Health Scholarship recipients required to meet the
    active duty service obligation prescribed under section 254m of
    Title 42 without regard to any competitive personnel system,
    agency personnel limitation, or Indian preference policy.]
        (e) Active Duty Service Requirement.--The active duty
    service obligation prescribed under section 338C of the Public
    Health Service Act (42 U.S.C. 254m) shall be met by each
    graduate who receives a stipend described in subsection (d)(4)
    that is funded under this section. Such obligation shall be met
    by service--
              (1) in an Indian Health Program;
              (2) in a program assisted under title V of this Act;
            or
              (3) in the private practice of psychology if, as
            determined by the Secretary, in accordance with
            guidelines promulgated by the Secretary, such practice
            is situated in a physician or other health professional
            shortage area and addresses the health care needs of a
            substantial number of Indians.
        (f) Authorization of Appropriations.--There is authorized
    to be appropriated to carry out this section $2,700,000 for
    each of fiscal years 2008 through 2017.

    SEC. 106. SCHOLARSHIP PROGRAMS FOR INDIAN TRIBES.

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

    [Sec. 1614. Indian Health Service extern programs]

    SEC. 107. INDIAN HEALTH SERVICE EXTERN PROGRAMS.

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

    [Sec. 1615. Continuing education allowances]

    SEC. 108. CONTINUING EDUCATION ALLOWANCES.

        [(a) Discretionary authority; scope of activities]
        In order to encourage [physicians, dentists, nurses, and
    other] scholarship and stipend recipients under sections 104,
    105, 106, and 115 and health professionals, including community
    health representatives and emergency medical technicians, to
    join or continue in [the Service] an Indian Health Program and
    to provide their services in the rural and remote areas where a
    significant portion of [the Indian people resides] Indians
    reside, the Secretary, acting through the Service, may
    [provide]--
              (1) provide programs or allowances to transition into
            an Indian Health Program, including licensing, board or
            certification examination assistance, and technical
            assistance in fulfilling service obligations under
            sections 104, 105, 106, and 115; and
              (2) provide programs or allowances to health
            professionals employed in [the Service] an Indian
            Health Program to enable them for a period of time each
            year prescribed by regulation of the Secretary to take
            leave of their duty stations for professional
            consultation, management, leadership, and refresher
            training courses.
        [(b) Limitation
        [Of amounts appropriated under the authority of this
    subchapter for each fiscal year to be used to carry out this
    section, not more than $1,000,000 may be used to establish
    postdoctoral training programs for health professionals.

    [Sec. 1616. Community Health Representative Program]

    SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PROGRAM.

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

    [Sec. 1616a. Indian Health Service Loan Repayment Program]

    SEC. 110. INDIAN HEALTH SERVICE LOAN REPAYMENT PROGRAM.

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

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

    SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOVERY FUND.

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

    [Sec. 1616b. Recruitment activities]

    SEC. 112. RECRUITMENT ACTIVITIES.

        (a) Reimbursement for Travel.--The Secretary, acting
    through the Service, may reimburse health professionals seeking
    positions [in the Service] with Indian Health Programs or Urban
    Indian Organizations, including individuals considering
    entering into a contract under section [1616a of this title,]
    110 and their spouses, for actual and reasonable expenses
    incurred in traveling to and from their places of residence to
    an area in which they may be assigned for the purpose of
    evaluating such area with respect to such assignment.
        [(b)] (b) Recruitment Personnel.--The Secretary, acting
    through the Service, shall assign [one] 1 individual in each
    [area office] Area Office to be responsible on a full-time
    basis for recruitment activities.

    [Sec. 1616c. Tribal recruitment and retention program]

    SEC. 113. INDIAN RECRUITMENT AND RETENTION PROGRAM.

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

    [Sec. 1616d. Advanced training and research]

    SEC. 114. ADVANCED TRAINING AND RESEARCH

        [(a) Establishment of program]
        (a) Demonstration Program.--The Secretary, acting through
    the Service, shall establish a [program] demonstration project
    to enable health professionals who have worked in an Indian
    Health Program or Urban Indian Organization for a substantial
    period of time to pursue advanced training or research [in]
    areas of study for which the Secretary determinates a need
    exists. [In selecting participants for a program established
    under this subsection, the Secretary, acting through the
    Service, shall give priority to applicants who are employed by
    the Indian Health Service, Indian tribes, tribal organizations,
    and urban Indian organizations, at the time of the submission
    of the applications.]
        [(b) Obligated service]
        (b) Service Obligation.--An individual who participates in
    a program under subsection (a) [of this section], where the
    educational costs are borne by the Service, shall incur an
    obligation to serve in an Indian [health program (as defined in
    section 1616a(a)(2) of this title)] Health Program or Urban
    Indian Organization for a period of obligated service equal to
    at least the period of time during which the individual
    participates in such program. In the event that the individual
    fails to complete such obligated service, the individual shall
    be liable to the United States for the period of service
    remaining. In such event, with respect to individuals entering
    the program after [October 29, 1992,] the date of enactment of
    the Indian Health Care Improvement Act Amendments of 2007, the
    United States shall be entitled to recover from such individual
    an amount to be determined in accordance with the formula
    specified in subsection (1) of section [1616a of this title]
    110 in the manner provided for in such subsection.
        [(c) Eligibility]
        (c) Equal Opportunity for Participation.--Health
    professionals from [Indian tribes and tribal and Indian
    organizations under the authority of the Indian Self
    Determination Act [25 U.S.C.A. Sec. 450f et seq.] Tribal Health
    Programs and Urban Indian Organizations shall be given an equal
    opportunity to participate in the program under subsection
    (a)[of this section].

    [Sec. 1616e. Nursing program]

    SEC. 115. QUENTIN N. BURDICK AMERICAN INDIANS INTO NURSING PROGRAM.

        (a) Grants.
        [The Secretary, acting through the Service, shall provide
    grants to--
              [(1) public or private schools of nursing,
              [(2) tribally controlled community colleges and
            tribally controlled postsecondary vocational
            institutions (as defined in section 2397h(2) of Title
            20), and]
              [(3) nurse midwife programs, and nurse practitioner
            programs, that are provided by any public or private
            institution, for] Authorized.--For the purpose of
            increasing the number of nurses, nurse midwives, and
            nurse practitioners who deliver health care services to
            Indians, the Secretary, acting through the Service,
            shall provide grants to the following:
              (1) Public or private schools of nursing.
              (2) Tribal colleges or universities.
              (3) Nurse midwife programs and advanced practice
            nurse programs that are provided by any tribal college
            or university accredited nursing program, or in the
            absence of such, any other public or private
            institutions.
        (b) [Purposes] Use of Grants._Grants provided under
    subsection (a) [of this section] may be used [to--] for 1 or
    more of the following:
              (1) To recruit individuals for programs which train
            individuals to be nurses, nurse midwives, or [nurse
            practitioners,] advanced practice nurses.
              (2) To provide scholarships to [individuals] Indians
            enrolled in such programs that may pay the tuition
            charged for such program and other expenses incurred in
            connection with such program, including books, fees,
            room and board, and stipends for living expenses[,].
              (3) To provide a program that encourages nurses,
            nurse midwives, and [nurse practitioners] advanced
            practice nurses to provide, or continue to provide,
            health care services to Indians[,].
              (4) To provide a program that increases the skills
            of, and provides continuing education to, nurses, nurse
            midwives, and [nurse practitioners, or] advanced
            practice nurses.
              (5) To provide any program that is designed to
            achieve the purpose described in subsection (a) [of
            this section].
        (c) [Application] Applications._Each application for a
    grant under subsection (a) [of this section] shall include such
    information as the Secretary may require to establish the
    connection between the program of the applicant and a health
    care facility that primarily serves Indians.
        [(d) Preference]
        (d) Preferences for Grant Recipients._In providing grants
    under subsection (a) [of this section], the Secretary shall
    extend a preference to[--] the following:
              (1) [programs] Programs that provide a preference to
            Indians[,].
              (2) [programs] Programs that train nurse midwives or
            [nurse practitioners,] advanced practice nurses.
              (3) [programs] Programs that are interdisciplinary[,
            and].
              (4) [programs] Programs that are conducted in
            cooperation with a [center] program for gifted and
            talented Indian students [established under section
            2624(a) of this title].
              (5) Programs conducted by tribal colleges and
            universities.
        (e) Quentin N. Burdick [American Indians Into Nursing]
    Program Grant._The Secretary shall provide [one] 1 of the
    grants authorized under subsection (a)[of this section] to
    establish and maintain a program at the University of North
    Dakota to be known as the ``Quentin N. Burdick American Indians
    Into Nursing Program''. Such program shall, to the maximum
    extent feasible, coordinate with the Quentin N. Burdick Indian
    Health Programs established under section [1616g] 117(b) [of
    this title] and the Quentin N. Burdick American Indians Into
    Psychology Program established under section [1621p] 105(b) [of
    this title].
        (f) Active Duty Service [obligation] Obligation._The active
    duty service obligation prescribed under section [254m of this
    title] 338C of the Public Health Service Act (42 U.S.C. 254m)
    shall be met by each individual who receives training or
    assistance described in paragraph (1) or (2) of subsection (b)
    [of this section] that is funded by a grant provided under
    subsection (a) [of this section]. Such obligation shall be met
    by service--
              [(A)] (1) in the [Indian Health] Service;
              [(B)] (2) in a program of an Indian Tribe or Tribal
            Organization conducted under [a contract entered into
            under] the Indian Self-Determination and Education
            Assistance Act [[](25 U.S.C.[A. Sec. ] 450[f et seq.];
            (C]  et seq.) (including programs under agreements with
            the Bureau of Indian Affairs);
              (3) in a program assisted under [subchapter IV] title
            V of this [chapter; or] Act;
              [(D)](4) in the private practice of nursing if, as
            determined by the Secretary, in accordance with
            guidelines promulgated by the Secretary, such practice
            is situated in a physician or other health
            [professional] shortage area and addresses the health
            care needs of a substantial number of Indians[.]; or
        [(g) Authorization of appropriations
        [Beginning with fiscal year 1993, of the amounts
    appropriated under the authority of this subchapter for each
    fiscal year to be used to carry out this section, not less than
    $1,000,000 shall be used to provide grants under subsection (a)
    of this section for the training of nurse midwives, nurse
    anesthetists, and nurse practitioners.

    [Sec. 1616e-1. Nursing school clinics

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

    [Sec. 1616f. Tribal culture and history]

    SEC. 116. TRIBAL CULTURAL ORIENTATION.

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

    [Sec. 1616g.]

    SEC. 117. INMED [PROGRAM] PROGRAM.

        (a) Grants Authorized.--The Secretary, acting through the
    Service, is authorized to provide grants to [at least 3]
    colleges and universities for the purpose of maintaining and
    expanding the [Native American] Indian health careers
    recruitment program known as the [``]`Indians [into] Into
    Medicine Program''' (hereinafter in this section referred to as
    ```INMED''') as a means of encouraging Indians to enter the
    health professions.
        [(b) University of North Dakota]
        (b) Quentin N. Burdick Grant.--The Secretary shall provide
    one1 of the grants authorized under subsection (a) to maintain
    the INMED program at the University of North Dakota, to be
    known as the [``]`Quentin N. Burdick Indian Health
    Programs['']', unless the Secretary makes a determination,
    based upon program reviews, that the program is not meeting the
    purposes of this section. Such program shall, to the maximum
    extent feasible, coordinate with the Quentin N. Burdick
    American Indians Into Psychology Program established under
    section [1621p] 105(b) [of this title] and the Quentin N.
    Burdick American Indians Into Nursing Program established under
    section [1616e(e) of this title.] 115.
        (c) Regulations[; contents of recruitment program (1)].--
    The Secretary, pursuant to this Act, shall develop regulations
    [for the competitive awarding of the] to govern grants
    [provided under] pursuant to this section.
        [(2)] (d) Requirements.--Applicants for grants provided
    under this section shall agree to provide a program which--
              [(A)] (1) provides outreach and recruitment for
            health professions to Indian communities including
            elementary[,] and secondary schools and community
            colleges located on [Indian] reservations which will be
            served by the program[,];
              [(B)] (2) incorporates a program advisory board
            comprised of representatives from the [tribes] Indian
            Tribes and Indian communities which will be served by
            the program[,];
              [(C)] (3) provides summer preparatory programs for
            Indian students who need enrichment in the subjects of
            math and science in order to pursue training in the
            health professions[,];
              [(D)] (4) provides tutoring, counseling, and support
            to students who are enrolled in a health career program
            of study at the respective college or university[,];
            and
              [(E)] (5) to the maximum extent feasible, employs
            qualified Indians in the program.
        [(d) Report to Congress
        [By no later than the date that is 3 years after November
    23, 1988, the Secretary shall submit a report to the Congress
    on the program established under this section including
    recommendations for expansion or changes to the program.

    [Sec. 1616h. Health training programs of community colleges]

    SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY COLLEGES.

        (a) Grants to Establish Programs.--
              (1) In general.--The Secretary, acting through the
            Service, shall award grants to accredited and
            accessible community colleges for the purpose of
            assisting [the community college] such community
            colleges in the establishment of programs which provide
            education in a health profession leading to a degree or
            diploma in a health profession for individuals who
            desire to practice such profession on [an Indian] or
            near a reservation or in [a tribal clinic] an Indian
            Health Program.
              (2) Amount of grants.--The amount of any grant
            awarded to a community college under paragraph (1) for
            the first year in which such a grant is provided to the
            community college shall not exceed $[100,000.] 250,000.
        [(b) Eligibility]
        (b) Grants for Maintenance and Recruiting.--
              [(1)] (1) In general.--The Secretary, acting through
            the Service, shall award grants to accredited and
            accessible community colleges that have established a
            program described in subsection (a)(1) [of this
            section] for the purpose of maintaining the program and
            recruiting students for the program.
              (2) Requirements.--Grants may only be made under this
            section to a community college which--
                      (A) is accredited[,];
                      (B) has [access to] a relationship with a
                    hospital facility, Service facility, or
                    hospital that could provide training of nurses
                    or health professionals[,];
                      (C) has entered into an agreement with an
                    accredited college or university medical
                    school, the terms of which--
                              (i) provide a program that enhances
                            the transition and recruitment of
                            students into advanced baccalaureate or
                            graduate programs [which] that train
                            health professionals[,]; and
                              (ii) stipulate certifications
                            necessary to approve internship and
                            field placement opportunities at
                            [service unit facilities of the Service
                            or at tribal health facilities,] Indian
                            Health Programs;
                      (D) has a qualified staff which has the
                    appropriate certifications[, and];
                      (E) is capable of obtaining State or regional
                    accreditation of the program described in
                    subsection (a)(1) [of]; and
                      (F) agrees to provide for Indian preference
                    for applicants for programs under this section.
        [(c) Agreements and technical assistance]
        (c) Technical Assistance.--The Secretary shall encourage
    community colleges described in subsection (b)(2) [of this
    section] to establish and maintain programs described in
    subsection (a)(1) [of this section] by--
              (1) entering into agreements with such colleges for
            the provision of qualified personnel of the Service to
            teach courses of study in such programs[,]; and
              (2) providing technical assistance and support to
            such colleges.
        (d) Advanced [training] Training.--
              (1) Required.--Any program receiving assistance under
            this section that is conducted with respect to a health
            profession shall also offer courses of study which
            provide advanced training for any health professional
            who--
                      [(1)] (A) has already received a degree or
                    diploma in such health profession[,]; and
                      [(2)] (B) provides clinical services on [an
                    Indian] or near a reservation[, at a Service
                    facility, or at a tribal clinic] or for an
                    Indian Health Program.
              (2) May be offered at alternate site.--Such courses
            of study may be offered in conjunction with the college
            or university with which the community college has
            entered into the agreement required under subsection
            (b)(2)(C) [of this section].
        [(e) Definitions
        [For purposes of this section--
              [(1) The term ``community college'' means--
                      [(A) a tribally controlled community college,
                    or
                      [(B) a junior or community college.
              [(2) The term ``tribally controlled community
            college'' has the meaning given to such term by section
            1801(4) of this title.
              [(3) The term ``junior or community college'' has the
            meaning given to such term by section 1058(e) of Title
            20.]
        (e) Priority.--Where the requirements of subsection (b) are
    met, grant award priority shall be provided to tribal colleges
    and universities in Service Areas where they exist.

    [Sec. 1616i. Additional incentives for health professionals]

    SEC. 119. RETENTION BONUS.

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

    [Sec. 1616j. Retention bonus

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

    [Sec. 1616k. Nursing residency program]

    SEC. 120. NURSING RESIDENCY PROGRAM.

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

    [Sec. 1616l. Community Health Aide Program for Alaska]

    SEC. 121. COMMUNITY HEALTH AIDE PROGRAM.

        [(a) Maintenance of program]
        (a) General Purposes of Program.--Under the authority of
    [section 13 of this title] the Act of November 2, 1921 (25
    U.S.C. 13) (commonly known as the ``Snyder Act'', the
    Secretary, acting through the Service, shall [maintain] develop
    and operate a Community Health Aide Program in Alaska under
    which the Service--
              (1) provides for the training of Alaska Natives as
            health aides or community health practitioners;
              (2) uses such aides or practitioners in the provision
            of health care, health promotion, and disease
            prevention services to Alaska Natives living in
            villages in rural Alaska; and
              (3) provides for the establishment of
            teleconferencing capacity in health clinics located in
            or near such villages for use by community health aides
            or community health practitioners.
        [(b) Training; curriculum; Certification Board]
        (b) Specific Program Requirements.--The Secretary, acting
    through the Community Health Aide Program of the Service,
    shall--
              (1) using trainers accredited by the Program, provide
            a high standard of training to community health aides
            and community health practitioners to ensure that such
            aides and practitioners provide quality health care,
            health promotion, and disease prevention services to
            the villages served by the Program;
              (2) in order to provide such training, develop a
            curriculum that--
                      (A) combines education in the theory of
                    health care with supervised practical
                    experience in the provision of health care;
                      (B) provides instruction and practical
                    experience in the provision of acute care,
                    emergency care, health promotion, disease
                    prevention, and the efficient and effective
                    management of clinic pharmacies, supplies,
                    equipment, and facilities; and
                      (C) promotes the achievement of the health
                    status objectives specified in section [1602(b)
                    of this title] 3(2);
              (3) establish and maintain a Community Health Aide
            Certification Board to certify as community health
            aides or community health practitioners individuals who
            have successfully completed the training described in
            paragraph (1) or can demonstrate equivalent experience;
              (4) develop and maintain a system which identifies
            the needs of community health aides and community
            health practitioners for continuing education in the
            provision of health care, including the areas described
            in paragraph (2)(B), and develop programs that meet the
            needs for such continuing education;
              (5) develop and maintain a system that provides close
            supervision of community health aides and community
            health practitioners; [and]
              (6) develop a system under which the work of
            community health aides and community health
            practitioners is reviewed and evaluated to assure the
            provision of quality health care, health promotion, and
            disease prevention services[.]; and
              (7) ensure that pulpal therapy (not including
            pulpotomies on deciduous teeth) or extraction of adult
            teeth can be performed by a dental health aide
            therapist only after consultation with a licensed
            dentist who determines that the procedure is a medical
            emergency that cannot be resolved with palliative
            treatment, and further that dental health aide
            therapists are strictly prohibited from performing all
            other oral or jaw surgeries, provided that
            uncomplicated extractions shall not be considered oral
            surgery under this section.
         (c) Program Review.--
              (1) Neutral panel.--
                      (A) Establishment.--The Secretary, acting
                    through the Service, shall establish a neutral
                    panel to carry out the study under paragraph
                    (2).
                      (B) Membership.--Members of the neutral panel
                    shall be appointed by the Secretary from among
                    clinicians, economists, community
                    practitioners, oral epidemiologists, and Alaska
                    Natives.
              (2) Study.--
                      (A) In general.--The neutral panel
                    established under paragraph (1) shall conduct a
                    study of the dental health aide therapist
                    services provided by the Community Health Aide
                    Program under this section to ensure that the
                    quality of care provided through those services
                    is adequate and appropriate.
                      (B) Parameters of study.--The Secretary, in
                    consultation with interested parties, including
                    professional dental organizations, shall
                    develop the parameters of the study.
                      (C) Inclusions.--The study shall include a
                    determination by the neutral panel with respect
                    to--
                              (i) the ability of the dental health
                            aide therapist services under this
                            section to address the dental care
                            needs of Alaska Natives;
                              (ii) the quality of care provided
                            through those services, including any
                            training, improvement, or additional
                            oversight required to improve the
                            quality of care; and
                              (iii) whether safer and less costly
                            alternatives to the dental health aide
                            therapist services exist.
                      (D) Consultation.--In carrying out the study
                    under this paragraph, the neutral panel shall
                    consult with Alaska Tribal Organizations with
                    respect to the adequacy and accuracy of the
                    study.
              (3) Report.--The neutral panel shall submit to the
            Secretary, the Committee on Indian Affairs of the
            Senate, and the Committee on Natural Resources of the
            House of Representatives a report describing the
            results of the study under paragraph (2), including a
            description of--
                      (A) any determination of the neutral panel
                    under paragraph (2)(C); and
                      (B) any comments received from an Alaska
                    Tribal Organization under paragraph (2)(D).
          (d) Nationalization of Program.--
              (1) In general.--Except as provided in paragraph (2),
            the Secretary, acting through the Service, may
            establish a national Community Health Aide Program in
            accordance with the program under this section, as the
            Secretary determines to be appropriate.

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

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

    [Sec. 1616n. Tribal health program administration]

    SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION.

        [The Secretary] The Secretary, acting through the Service,
    shall, by contract or otherwise, provide training for
    [individuals] Indians in the administration and planning of
    [tribal health programs] Tribal Health Programs.

    SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE DEMONSTRATION PROGRAMS.

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

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

    SEC. 124. NATIONAL HEALTH SERVICE CORPS.

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

    SEC. 125. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL CURRICULA DEMONSTRATION
                        PROGRAMS.

        (a) Contracts and Grants.--The Secretary, acting through
    the Service, may enter into contracts with, or make grants to,
    accredited tribal colleges and universities and eligible
    accredited and accessible community colleges to establish
    demonstration programs to develop educational curricula for
    substance abuse counseling.
        (b) Use of Funds.--Funds provided under this section shall
    be used only for developing and providing educational
    curriculum for substance abuse counseling (including paying
    salaries for instructors). Such curricula may be provided
    through satellite campus programs.
        (c) Time Period of Assistance; Renewal.--A contract entered
    into or a grant provided under this section shall be for a
    period of 3 years. Such contract or grant may be renewed for an
    additional 2-year period upon the approval of the Secretary.
        (d) Criteria for Review and Approval of Applications.--Not
    later than 180 days after the date of enactment of the Indian
    Health Care Improvement Act Amendments of 2007, the Secretary,
    after consultation with Indian Tribes and administrators of
    tribal colleges and universities and eligible accredited and
    accessible community colleges, shall develop and issue criteria
    for the review and approval of applications for funding
    (including applications for renewals of funding) under this
    section. Such criteria shall ensure that demonstration programs
    established under this section promote the development of the
    capacity of such entities to educate substance abuse
    counselors.
        (e) Assistance.--The Secretary shall provide such technical
    and other assistance as may be necessary to enable grant
    recipients to comply with the provisions of this section.
        (f) Report.--Each fiscal year, the Secretary shall submit
    to the President, for inclusion in the report which is required
    to be submitted under section 801 for that fiscal year, a
    report on the findings and conclusions derived from the
    demonstration programs conducted under this section during that
    fiscal year.
        (g) Definition.--For the purposes of this section, the term
    ``educational curriculum'' means 1 or more of the following:
              (1) Classroom education.
              (2) Clinical work experience.
              (3) Continuing education workshops.

    SEC. 126. BEHAVIORAL HEALTH TRAINING AND COMMUNITY EDUCATION PROGRAMS.

        (a) Study; List.--The Secretary, acting through the
    Service, and the Secretary of the Interior, in consultation
    with Indian Tribes and Tribal Organizations, shall conduct a
    study and compile a list of the types of staff positions
    specified in subsection (b) whose qualifications include, or
    should include, training in the identification, prevention,
    education, referral, or treatment of mental illness, or
    dysfunctional and self destructive behavior.
        (b) Positions.--The positions referred to in subsection (a)
    are--
              (1) staff positions within the Bureau of Indian
            Affairs, including existing positions, in the fields
            of--
                      (A) elementary and secondary education;
                      (B) social services and family and child
                    welfare;
                      (C) law enforcement and judicial services;
                    and
                      (D) alcohol and substance abuse;
              (2) staff positions within the Service; and
              (3) staff positions similar to those identified in
            paragraphs (1) and (2) established and maintained by
            Indian Tribes, Tribal Organizations (without regard to
            the funding source), and Urban Indian Organizations.
        (c) Training Criteria.--
              (1) In general.--The appropriate Secretary shall
            provide training criteria appropriate to each type of
            position identified in subsection (b)(1) and (b)(2) and
            ensure that appropriate training has been, or shall be
            provided to any individual in any such position. With
            respect to any such individual in a position identified
            pursuant to subsection (b)(3), the respective
            Secretaries shall provide appropriate training to, or
            provide funds to, an Indian Tribe, Tribal Organization,
            or Urban Indian Organization for training of
            appropriate individuals. In the case of positions
            funded under a contract or compact under the Indian
            Self-Determination and Education Assistance Act (25
            U.S.C. 450 et seq.), the appropriate Secretary shall
            ensure that such training costs are included in the
            contract or compact, as the Secretary determines
            necessary.
              (2) Position specific training criteria.--Position
            specific training criteria shall be culturally relevant
            to Indians and Indian Tribes and shall ensure that
            appropriate information regarding traditional health
            care practices is provided.
        (d) Community Education on Mental Illness.--The Service
    shall develop and implement, on request of an Indian Tribe,
    Tribal Organization, or Urban Indian Organization, or assist
    the Indian Tribe, Tribal Organization, or Urban Indian
    Organization to develop and implement, a program of community
    education on mental illness. In carrying out this subsection,
    the Service shall, upon request of an Indian Tribe, Tribal
    Organization, or Urban Indian Organization, provide technical
    assistance to the Indian Tribe, Tribal Organization, or Urban
    Indian Organization to obtain and develop community educational
    materials on the identification, prevention, referral, and
    treatment of mental illness and dysfunctional and self-
    destructive behavior.

    [Sec. 1616p. Authorization of appropriations]

        (e) Plan.--Not later than 90 days after the date of
    enactment of the Indian Health Care Improvement Act Amendments
    of 2007, the Secretary shall develop a plan under which the
    Service will increase the health care staff providing
    behavioral health services by at least 500 positions within 5
    years after the date of enactment of this section, with at
    least 200 of such positions devoted to child, adolescent, and
    family services. The plan developed under this subsection shall
    be implemented under the Act of November 2, 1921 (25 U.S.C. 13)
    (commonly known as the ``Snyder Act'').

    SEC. 127. AUTHORIZATION OF APPROPRIATIONS.

        There are authorized to be appropriated such sums as may be
    necessary for each fiscal year through fiscal year [2000] 2017
    to carry out this [subchapter] title.

                           TITLE II--HEALTH SERVICES

    [Sec. 1621. Indian Health Care Improvement Fund]

    SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND.

        [(a) Approved expenditures]
        (a) Use of Funds.--The Secretary, acting through the
    Service, is authorized to expend funds, directly or under the
    authority of the Indian Self-Determination and Education
    Assistance Act (25 U.S.C. 450 et seq.), which are appropriated
    under the authority of this section, [through the Service,] for
    the purposes of--
              (1) eliminating the deficiencies in health status and
            health resources of all Indian [tribes,] Tribes;
              (2) eliminating backlogs in the provision of health
            care services to Indians[,];
              (3) meeting the health needs of Indians in an
            efficient and equitable manner, [and] including the use
            of telehealth and telemedicine when appropriate;
              (4) eliminating inequities in funding for both direct
            care and contract health service programs; and
              [(4)] (5) augmenting the ability of the Service to
            meet the following health service responsibilities[,
            either through direct or contract care or through
            contracts entered into pursuant to the Indian Self-
            Determination Act [25 U.S.C.A. Sec. 450f et seq.],]
            with respect to those Indian [tribes] Tribes with the
            highest levels of health status deficiencies and
            resource deficiencies:
                      (A) [clinical] Clinical care [(direct and
                    indirect)], including inpatient care,
                    outpatient care (including audiology, clinical
                    eye, and vision care[;]), primary care,
                    secondary and tertiary care, and long-term
                    care.
                      (B) [preventive] Preventive health, including
                    [screening] mammography and other cancer
                    screening in accordance with section [1621k of
                    this title;] 207.
                      [(C) dental care (direct and indirect);] (C)
                    Dental care.
                      (D) [mental] Mental health, including
                    community mental health services, inpatient
                    mental health services, dormitory mental health
                    services, therapeutic and residential treatment
                    centers, and training of traditional [Indian]
                    health care practitioners[;].
                      (E) [emergency] Emergency medical
                    services[;].
                      (F) [treatment] Treatment and control of, and
                    rehabilitative care related to, alcoholism and
                    drug abuse (including fetal alcohol syndrome)
                    among Indians[;].
                      (G) [accident] Injury prevention programs[;],
                    including data collection and evaluation,
                    demonstration projects, training, and capacity
                    building.
                      (H) [home] Home health care[;].
                      (I) [community] Community health
                    representatives[; and].
                      [(J) maintenance and repair.]
        [(b) Effect of other appropriations; allocation to service
    units]
                      (J) Maintenance and improvement.
        [(1)] (b) No Offset or Limitation._Any funds appropriated
    under the authority of this section shall not be used to offset
    or limit any other appropriations made to the Service under
    [section 13 of this title] this Act or the Act of November 2,
    1921 (25 U.S.C. 13) (commonly known as the ``Snyder Act''), or
    any other provision of law.
        (c) Allocation; Use.--
              [(2)] (1)[(A)] In general._Funds appropriated under
            the authority of this section [may] shall be allocated
            [on a service unit basis] to Service Units, Indian
            Tribes, or Tribal Organizations. The funds allocated to
            each [service unit] Indian Tribe, Tribal Organization,
            or Service Unit under this [subparagraph] paragraph
            shall be used by the [service unit to reduce] Indian
            Tribe, Tribal Organization, or Service Unit under this
            paragraph to improve the health status and reduce the
            resource deficiency of each [tribe] Indian Tribe served
            by such [service unit] Service Unit, Indian Tribe, or
            Tribal Organization.
              [B] (2) Apportionment of allocated funds._The
            apportionment of funds allocated to a [service unit
            under subparagraph (A)] Service Unit, Indian Tribe, or
            Tribal Organization under paragraph (1) among the
            health service responsibilities described in subsection
            (a)[(4) of this section] (5) shall be determined by the
            Service in consultation with, and with the active
            participation of, the affected Indian [tribes] Tribes
            and Tribal Organizations.
        [(c) Health Resources Deficiency Levels.--For] (d)
    Provisions Relating to Health Status and Resource
    Deficiencies._For the purposes of this section--, the following
    definitions apply:
              (1) Definition._The term ``health status and resource
            deficiency'' means the extent to which--
                      (A) the health status objectives set forth in
                    section [1602(b) of this title] 3(2) are not
                    being achieved; and
                      (B) the Indian [tribe] Tribe or Tribal
                    Organization does not have available to it the
                    health resources it needs, taking into account
                    the actual cost of providing health care
                    services given local geographic, climatic,
                    rural, or other circumstances.
              (2) Available resources._The health resources
            available to an Indian [tribe] Tribe or Tribal
            Organization include health resources provided by the
            Service as well as health resources used by the Indian
            [tribe] Tribe or Tribal Organization, including
            services and financing systems provided by any Federal
            programs, private insurance, and programs of State or
            local governments.
              (3) Process for review of determinations._The
            Secretary shall establish procedures which allow any
            Indian [tribe] Tribe or Tribal Organization to petition
            the Secretary for a review of any determination of the
            extent of the health status and resource deficiency of
            such [tribe] Indian Tribe or Tribal Organization.
        [(d) Programs administered by Indian tribe]
              [(1) Programs administered by any Indian tribe or
            tribal organization under the authority of the Indian
            Self-Determination Act] (e) Eligibility for Funds._
            Tribal Health Programs shall be eligible for funds
            appropriated under the authority of this section on an
            equal basis with programs that are administered
            directly by the Service.
              [(2) If any funds allocated to a tribe or service
            unit under the authority of this section are used for a
            contract entered into under the Indian Self-
            Determination Act [25 U.S.C.A. Sec. 450f et seq.], a
            reasonable portion of such funds may be used for health
            planning, training, technical assistance, and other
            administrative support functions.]
        [(e)] (f) Report [to Congress].--By no later than the date
    that is 3 years after [October 29, 1992,] the date of enactment
    of the Indian Health Care Improvement Act Amendments of 2007,
    the Secretary shall submit to the Congress the current health
    status and resource deficiency report of the Service for each
    [Indian tribe or service unit] Service Unit, including newly
    recognized or acknowledged [tribes] Indian Tribes. Such report
    shall set out--
              (1) the methodology then in use by the Service for
            determining [tribal] Tribal health status and resource
            deficiencies, as well as the most recent application of
            that methodology;
              (2) the extent of the health status and resource
            deficiency of each Indian [tribe] Tribe served by the
            Service or a Tribal Health Program;
              (3) the amount of funds necessary to eliminate the
            health status and resource deficiencies of all Indian
            [tribes] Tribes served by the Service or a Tribal
            Health Program; and
              (4) an estimate of--
                      (A) the amount of health service funds
                    appropriated under the authority of this
                    [chapter] Act, or any other Act, including the
                    amount of any funds transferred to the
                    Service[,] for the preceding fiscal year which
                    is allocated to each [service unit] Service
                    Unit, Indian [tribe] Tribe, or [comparable
                    entity] Tribal Organization;
                      (B) the number of Indians eligible for health
                    services in each [service unit] Service Unit or
                    Indian [tribe; and] Tribe or Tribal
                    Organization; and
                      (C) the number of Indians using the Service
                    resources made available to each [service unit
                    or Indian tribe.] Service Unit, Indian Tribe or
                    Tribal Organization, and, to the extent
                    available, information on the waiting lists and
                    number of Indians turned away for services due
                    to lack of resources.
        [(f) Appropriated funds included in base budget of Service]
        (g) Inclusion in Base Budget._Funds appropriated under
    [authority of] this section for any fiscal year shall be
    included in the base budget of the Service for the purpose of
    determining appropriations under this section in subsequent
    fiscal years.
        [(g) Continuation of Service responsibilities for backlogs
    and parity ]
        (h) Clarification._Nothing in this section is intended to
    diminish the primary responsibility of the Service to eliminate
    existing backlogs in unmet health care needs, nor are the
    provisions of this section intended to discourage the Service
    from undertaking additional efforts to achieve [parity] equity
    among Indian [tribes.] Tribes and Tribal Organizations.
        [(h) Authorization of appropriations]
        (i) Funding Designation._Any funds appropriated under the
    authority of this section shall be designated as the
    [``]`Indian Health Care Improvement Fund.['']'

    [Sec. 1621a. Catastrophic Health Emergency Fund]

    SEC. 202. CATASTROPHIC HEALTH EMERGENCY FUND.

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

    SEC. 203. HEALTH PROMOTION AND DISEASE PREVENTION SERVICES.

        (a) Findings.--Congress finds that health promotion and
    disease prevention activities--
              (1) improve the health and well-being of Indians; and

    [Sec. 1621b. Health promotion and disease prevention services]

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

    [Sec. 1621c. Diabetes prevention, treatment, and control]

    SEC. 204. DIABETES PREVENTION, TREATMENT, AND CONTROL.

        [(a) Incidence and complications]
        (a) Determinations Regarding Diabetes.--The Secretary,
    acting through the Service, and in consultation with [the
    tribes] Indian Tribes and Tribal Organizations, shall
    determine--
              (1) by [tribe] Indian Tribe and by Service [unit of
            the Service] Unit, the incidence of, and the types of
            complications resulting from, diabetes among Indians;
            and
              (2) based on the determinations made pursuant to
            paragraph (1), the measures (including patient
            education and effective ongoing monitoring of disease
            indicators) each Service [unit] Unit should take to
            reduce the incidence of, and prevent, treat, and
            control the complications resulting from, diabetes
            among [tribes] Indian Tribes within that Service [unit]
            Unit.
        (b) Diabetes Screening.--[The]To the extent medically
    indicated and with informed consent, the Secretary shall screen
    each Indian who receives services from the Service for diabetes
    and for conditions which indicate a high risk that the
    individual will become diabetic and establish a cost-effective
    approach to ensure ongoing monitoring of disease indicators.
    Such screening [may be done by a tribe or tribal organization
    operating health care programs or facilities with funds from
    the Service under the Indian Self-Determination Act [25
    U.S.C.A. Sec. 450f et seq.].] and monitoring may be conducted
    by a Tribal Health Program and may be conducted through
    appropriate Internet-based health care management programs.
        [(c) Model diabetes projects]
        [(1)] (c) Diabetes projects.--The Secretary shall continue
    to maintain through [fiscal year 2000] each model diabetes
    project in existence on [October 29, 1992 and located--] the
    date of enactment of the Indian Health Care Improvement Act
    Amendments of 2007, any such other diabetes programs operated
    by the Service or Tribal Health Programs, and any additional
    diabetes projects, such as the Medical Vanguard program
    provided for in title IV of Public Law 108-87, as implemented
    to serve Indian Tribes. Tribal Health Programs shall receive
    recurring funding for the diabetes projects that they operate
    pursuant to this section, both at the date of enactment of the
    Indian Health Care Improvement Act Amendments of 2007 and for
    projects which are added and funded thereafter.
                     [(A) at the Claremore Indian Hospital in
                    Oklahoma;
                     [(B) at the Fort Totten Health Center in North
                    Dakota;
                     [(C) at the Sacaton Indian Hospital in
                    Arizona;
                     [(D) at the Winnebago Indian Hospital in
                    Nebraska;
                     [(E) at the Albuquerque Indian Hospital in New
                    Mexico;
                     [(F) at the Perry, Princeton, and Old Town
                    Health Centers in Maine;
                     [(G) at the Bellingham Health Center in
                    Washington;
                     [(H) at the Fort Berthold Reservation;
                     [(I) at the Navajo Reservation;
                     [(J) at the Papago Reservation;
                     [(K) at the Zuni Reservation; or
                     [(L) in the States of Alaska, California,
                    Minnesota, Montana, Oregon, or Utah.
             [(2) The Secretary may establish new model diabetes
            projects under this section taking into consideration
            applications received under this section from all
            service areas, except that the Secretary may not
            establish a greater number of such projects in one
            service area than in any other service area until there
            is an equal number of such projects established with
            respect to all service areas from which the Secretary
            receives qualified applications during the application
            period (as determined by the Secretary).
        [(d) Control officer; registry of patients
        [The Secretary shall--]
        (d) Dialysis Programs.--The Secretary is authorized to
    provide, through the Service, Indian Tribes, and Tribal
    Organizations, dialysis programs, including the purchase of
    dialysis equipment and the provision of necessary staffing.
        (e) Other Duties of the Secretary.--
             (1) In general.--The Secretary shall, to the extent
            funding is available--
              [(1) employ in each area office of the Service at
            least one diabetes control officer who shall coordinate
            and manage on a full-time basis activities within that
            area office] (A) in each Area Office, consult with
            Indian Tribes and Tribal Organizations regarding
            programs for the prevention, treatment, and control of
            diabetes;
              [(2) establish in each area office of the Service]
            (B) establish in each Area Office a registry of
            patients with diabetes to track the incidence of
            diabetes and the complications from diabetes in that
            area; and
              [(3)](C) ensure that data collected in each [area
            office] Area Office regarding diabetes and related
            complications among Indians [is] are disseminated to
            all other [area offices; and (4) evaluate the
            effectiveness of services provided through model
            diabetes projects established under this section] Area
            Offices, subject to applicable patient privacy laws.
        [(e) Authorization of appropriations
        [Funds appropriated under this section in any fiscal year
    shall be in addition to base resources appropriated to the
    Service for that year.]
              (2) Diabetes control officers.--
                     (A) In general.--The Secretary may establish
                    and maintain in each Area Office a position of
                    diabetes control officer to coordinate and
                    manage any activity of that Area Office
                    relating to the prevention, treatment, or
                    control of diabetes to assist the Secretary in
                    carrying out a program under this section or
                    section 330C of the Public Health Service Act
                    (42 U.S.C. 254c-3).
                      (B) Certain activities.--Any activity carried
                    out by a diabetes control officer under
                    subparagraph (A) that is the subject of a
                    contract or compact under the Indian Self-
                    Determination and Education Assistance Act (25
                    U.S.C. 450 et seq.), and any funds made
                    available to carry out such an activity, shall
                    not be divisible for purposes of that Act.

    SEC. 205. SHARED SERVICES FOR LONG-TERM CARE.

        (a) Long-Term Care.--Notwithstanding any other provision of
    law, the Secretary, acting through the Service, is authorized
    to provide directly, or enter into contracts or compacts under
    the Indian Self-Determination and Education Assistance Act (25
    U.S.C. 450 et seq.) with Indian Tribes or Tribal Organizations
    for, the delivery of long-term care (including health care
    services associated with long-term care) provided in a facility
    to Indians. Such agreements shall provide for the sharing of
    staff or other services between the Service or a Tribal Health
    Program and a long-term care or related facility owned and
    operated (directly or through a contract or compact under the
    Indian Self-Determination and Education Assistance Act (25
    U.S.C. 450 et seq.)) by such Indian Tribe or Tribal
    Organization.
        (b) Contents of Agreements.--An agreement entered into
    pursuant to subsection (a)--

    [Sec. 1621d. Hospice care feasibility study]

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

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

              (3) may authorize such Indian Tribe or Tribal
            Organization to construct, renovate, or expand a long-
            term care or other similar facility (including the
            construction of a facility attached to a Service
            facility).
        [(a) Right of recovery
        [Except as provided in subsection (f) of this section, the
    United States, an Indian tribe, or a tribal organization shall
    have the right to recover the reasonable expenses incurred by
    the Secretary, an Indian tribe, or a tribal organization in
    providing health services, through the Service, an Indian
    tribe, or a tribal organization, to any individual to the same
    extent that such individual, or any nongovernmental provider of
    such services, would be eligible to receive reimbursement or
    indemnification for such expenses if--
              [(1) such services had been provided by a
            nongovernmental provider, and
              [(2) such individual had been required to pay such
            expenses and did pay such expenses.
        [(b) Recovery against State with workers' compensation laws
    or no-fault automobile accident insurance program
        [Subsection (a) of this section shall provide a right of
    recovery against any State only if the injury, illness, or
    disability for which health services were provided is covered
    under--
              [(1) workers' compensation laws, or
              [(2) a no-fault automobile accident insurance plan or
            program.
        [(c) Prohibition of State law or contract provision
    impeding right of recovery
        [No law of any State, or of any political subdivision of a
    State, and no provision of any contract entered into or renewed
    after November 23, 1988, shall prevent or hinder the right of
    recovery of the United States, an Indian tribe, or a tribal
    organization under subsection (a) of this section.
        [(d) Right to damages
        [No action taken by the United States, an Indian tribe, or
    a tribal organization to enforce the right of recovery provided
    under subsection (a) of this section shall affect the right of
    any person to any damages (other than damages for the cost of
    health services provided by the Secretary through the Service).
        [(e) Intervention or separate civil action
        [The United States, an Indian tribe, or a tribal
    organization may enforce the right of recovery provided under
    subsection (a) of this section by--
              [(1) intervening or joining in any civil action or
            proceeding brought--
                      [(A) by the individual for whom health
                    services were provided by the Secretary, an
                    Indian tribe, or a tribal organization, or
                      [(B) by any representative or heirs of such
                    individual, or
              [(2) instituting a separate civil action, after
            providing to such individual, or to the representative
            or heirs of such individual, notice of the intention of
            the United States, an Indian tribe, or a tribal
            organization to institute a separate civil action.
        [(f) Right of recovery for services when self-insurance
    plan provides coverage
        [The United States shall not have a right of recovery under
    this section if the injury, illness, or disability for which
    health services were provided is covered under a self-insurance
    plan funded by an Indian tribe or tribal organization.]
        (c) Minimum Requirement.--Any nursing facility provided for
    under this section shall meet the requirements for nursing
    facilities under section 1919 of the Social Security Act.

    [Sec. 1621f. Crediting of reimbursements]

        (d) Other Assistance.--The Secretary shall provide such
    technical and other assistance as may be necessary to enable
    applicants to comply with the provisions of this section.
        [(a) Except as provided in section 1621a(d) of this title,
    subchapter III-A of this chapter, and section 1680c of this
    title, all reimbursements received or recovered, under
    authority of this chapter, Public Law 87-693 (42 U.S.C. 2651,
    et seq.), or any other provision of law, by reason of the
    provision of health services by the Service or by a tribe or
    tribal organization under a contract pursuant to the Indian
    Self-Determination Act [25 U.S.C.A. Sec. 450f et seq.] shall be
    retained by the Service or that tribe or tribal organization
    and shall be available for the facilities, and to carry out the
    programs, of the Service or that tribe or tribal organization
    to provide health care services to Indians.
        [(b) The Service may not offset or limit the amount of
    funds obligated to any service unit or any entity under
    contract with the Service because of the receipt of
    reimbursements under subsection (a) of this section.]
        (e) Use of Existing or Underused Facilities.--The Secretary
    shall encourage the use of existing facilities that are
    underused or allow the use of swing beds for long-term or
    similar care.

    [Sec. 1621g. Health services research]

    SEC. 206. HEALTH SERVICES RESEARCH.

        [Of the amounts appropriated for]
        (a) In General.--The Secretary, acting through the Service
    [in any fiscal year, other than amounts made available for the
    Indian Health Care Improvement Fund, not less than $200,000
    shall be available only], shall make funding available for
    research to further the performance of the health service
    responsibilities of [the Service. Indian tribes and tribal
    organizations contracting with the Service under the authority
    of the Indian Self-Determination Act [25 U.S.C.A. Sec. 450f et
    seq.]] Indian Health Programs.
        (b) Coordination of Resources and Activities.--The
    Secretary shall also, to the maximum extent practicable,
    coordinate departmental research resources and activities to
    address relevant Indian Health Program research needs.
        (c) Availability.--Tribal Health Programs shall be given an
    equal opportunity to compete for, and receive, research funds
    under this section.

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

        [(a) National plan for Indian Mental Health Services
              [(1) Not later than 120 days after November 28, 1990,
            the Secretary, acting through the Service, shall
            develop and publish in the Federal Register a final
            national plan for Indian Mental Health Services. The
            plan shall include--
                      [(A) an assessment of the scope of the
                    problem of mental illness and dysfunctional and
                    self-destructive behavior, including child
                    abuse and family violence, among Indians,
                    including--
                              [(i) the number of Indians served by
                            the Service who are directly or
                            indirectly affected by such illness or
                            behavior, and
                              [(ii) an estimate of the financial
                            and human cost attributable to such
                            illness or behavior;
                      [(B) an assessment of the existing and
                    additional resources necessary for the
                    prevention and treatment of such illness and
                    behavior; and
                      [(C) an estimate of the additional funding
                    needed by the Service to meet its
                    responsibilities under the plan.
              [(2) The Secretary shall submit a copy of the
            national plan to the Congress.
        [(b) Memorandum of agreement
        [Not later than 180 days after November 28, 1990, the
    Secretary and the Secretary of the Interior shall develop and
    enter into a memorandum of agreement under which the
    Secretaries shall, among other things--
              [(1) determine and define the scope and nature of
            mental illness and dysfunctional and self-destructive
            behavior, including child abuse and family violence,
            among Indians;
              [(2) make an assessment of the existing Federal,
            tribal, State, local, and private services, resources,
            and programs available to provide mental health
            services for Indians;
              [(3) make an initial determination of the unmet need
            for additional services, resources, and programs
            necessary to meet the needs identified pursuant to
            paragraph (1);
              [(4)(A) ensure that Indians, as citizens of the
            United States and of the States in which they reside,
            have access to mental health services to which all
            citizens have access;
              [(B) determine the right of Indians to participate
            in, and receive the benefit of, such services; and
              [(C) take actions necessary to protect the exercise
            of such right;
              [(5) delineate the responsibilities of the Bureau of
            Indian Affairs and the Service, including mental health
            identification, prevention, education, referral, and
            treatment services (including services through
            multidisciplinary resource teams), at the central,
            area, and agency and service unit levels to address the
            problems identified in paragraph (1);
              [(6) provide a strategy for the comprehensive
            coordination of the mental health services provided by
            the Bureau of Indian Affairs and the Service to meet
            the needs identified pursuant to paragraph (1),
            including--
                      [(A) the coordination of alcohol and
                    substance abuse programs of the Service, the
                    Bureau of Indian Affairs, and the various
                    tribes (developed under the Indian Alcohol and
                    Substance Abuse Prevention and Treatment Act of
                    1986) [25 U.S.C.A. Sec. 2401 et seq.] with the
                    mental health initiatives pursuant to this Act,
                    particularly with respect to the referral and
                    treatment of dually-diagnosed individuals
                    requiring mental health and substance abuse
                    treatment; and
                      [(B) ensuring that Bureau of Indian Affairs
                    and Service programs and services (including
                    multidisciplinary resource teams) addressing
                    child abuse and family violence are coordinated
                    with such non-Federal programs and services;
              [(7) direct appropriate officials of the Bureau of
            Indian Affairs and the Service, particularly at the
            agency and service unit levels, to cooperate fully with
            tribal requests made pursuant to subsection (d) of this
            section; and
              [(8) provide for an annual review of such agreement
            by the two Secretaries.
        [(c) Community mental health plan
              [(1) The governing body of any Indian tribe may, at
            its discretion, adopt a resolution for the
            establishment of a community mental health plan
            providing for the identification and coordination of
            available resources and programs to identify, prevent,
            or treat mental illness or dysfunctional and self-
            destructive behavior, including child abuse and family
            violence, among its members.
              [(2) In furtherance of a plan established pursuant to
            paragraph (1) and at the request of a tribe, the
            appropriate agency, service unit, or other officials of
            the Bureau of Indian Affairs and the Service shall
            cooperate with, and provide technical assistance to,
            the tribe in the development of such plan. Upon the
            establishment of such a plan and at the request of the
            tribe, such officials, as directed by the memorandum of
            agreement developed pursuant to subsection (c), of this
            section, shall cooperate with the tribe in the
            implementation of such plan.
              [(3) Two or more Indian tribes may form a coalition
            for the adoption of resolutions and the establishment
            and development of a joint community mental health plan
            under this subsection.
              [(4) The Secretary, acting through the Service, may
            make grants to Indian tribes adopting a resolution
            pursuant to paragraph (1) to obtain technical
            assistance for the development of a community mental
            health plan and to provide administrative support in
            the implementation of such plan.
        [(d) Mental health training and community education
    programs
              [(1) The Secretary and the Secretary of the Interior,
            in consultation with representatives of Indian tribes,
            shall conduct a study and compile a list, of the types
            of staff positions specified in paragraph (2) whose
            qualifications include, or should include, training in
            the identification, prevention, education, referral, or
            treatment of mental illness or dysfunctional and self-
            destructive behavior.
              [(2) The positions referred to in paragraph (1) are--
                      [(A) staff positions within the Bureau of
                    Indian Affairs, including existing positions,
                    in the fields of--
                              [(i) elementary and secondary
                            education;
                              [(ii) social services and family and
                            child welfare;
                              [(iii) law enforcement and judicial
                            services; and
                              [(iv) alcohol and substance abuse;
                      [(B) staff positions with the Service; and
                      [(C) staff positions similar to those
                    identified in subparagraphs (A) and (B)
                    established and maintained by Indian tribes,
                    including positions established in contracts
                    entered into under the Indian Self-
                    Determination Act [25 U.S.C.A. Sec. 450f et
                    seq.].
              [(3)(A) The appropriate Secretary shall provide
            training criteria appropriate to each type of position
            identified in paragraph (2)(A) and ensure that
            appropriate training has been, or will be, provided to
            any individual in any such position. With respect to
            any such individual in a position identified pursuant
            to paragraph (2)(C), the respective Secretaries shall
            provide appropriate training to, or provide funds to an
            Indian tribe for the training of, such individual. In
            the case of positions funded under a contract entered
            into under the Indian Self-Determination Act [25
            U.S.C.A. Sec. 450f et seq.], the appropriate Secretary
            shall ensure that such training costs are included in
            the contract, if necessary.
              [(B) Funds authorized to be appropriated pursuant to
            this section may be used to provide training authorized
            by this paragraph for community education programs
            described in paragraph (5) if a plan adopted pursuant
            to subsection (d) of this section identifies
            individuals or employment categories, other than those
            identified pursuant to paragraph (1), for which such
            training or community education is deemed necessary or
            desirable.
              [(4) Position-specific training criteria described in
            paragraph (3) shall be culturally relevant to Indians
            and Indian tribes and shall ensure that appropriate
            information regarding traditional Indian healing and
            treatment practices is provided.
              [(5) The Service shall develop and implement or, upon
            the request of an Indian tribe, assist such tribe to
            develop and implement, a program of community education
            on mental illness and dysfunctional and self-
            destructive behavior for individuals, as determined in
            a plan adopted pursuant to subsection (d) of this
            section. In carrying out this paragraph, the Service
            shall provide, upon the request of an Indian tribe,
            technical assistance to the Indian tribe to obtain or
            develop community education and training materials on
            the identification, prevention, referral, and treatment
            of mental illness and dysfunctional and self-
            destructive behavior.
        [(e) Staffing
              [(1) Within 90 days after November 28, 1990, the
            Secretary shall develop a plan under which the Service
            will increase the health care staff providing mental
            health services by at least 500 positions within five
            years after November 28, 1990, with at least 200 of
            such positions devoted to child, adolescent, and family
            services. Such additional staff shall be primarily
            assigned to the service unit level for services which
            shall include outpatient, emergency, aftercare and
            follow-up, and prevention and education services.
            [(2) The plan developed under paragraph (1) shall be
            implemented section 13 of this title.
        [(f) Staff recruitment and retention
              [(1) The Secretary shall provide for the recruitment
            of the additional personnel required by subsection (f)
            of this section and the retention of all Service
            personnel providing mental health services. In carrying
            out this subsection, the Secretary shall give priority
            to practitioners providing mental health services to
            children and adolescents with mental health problems.
              [(2) In carrying out paragraph (1), the Secretary
            shall develop a program providing for--
                      [(A) the payment of bonuses (which shall not
                    be more favorable than those provided for under
                    sections 1616i and 1616j of this title) for
                    service in hardship posts;
                      [(B) the repayment of loans (for which the
                    provisions of repayment contracts shall not be
                    more favorable than the repayment contracts
                    under section 1616a of this title) for health
                    professions education as a recruitment
                    incentive; and
                      [(C) a system of postgraduate rotations as a
                    retention incentive.
              [(3) This subsection shall be carried out in
            coordination with the recruitment and retention
            programs under subchapter I of this chapter.
        [(g) Mental Health Technician program
              [(1) Under the authority of section 13 of this title,
            the Secretary shall establish and maintain a Mental
            Health Technician program within the Service which--
                      [(A) provides for the training of Indians as
                    mental health technicians; and
                      [(B) employs such technicians in the
                    provision of community-based mental health care
                    that includes identification, prevention,
                    education, referral, and treatment services.
              [(2) In carrying out paragraph (1)(A), the Secretary
            shall provide high standard paraprofessional training
            in mental health care necessary to provide quality care
            to the Indian communities to be served. Such training
            shall be based upon a curriculum developed or approved
            by the Secretary which combines education in the theory
            of mental health care with supervised practical
            experience in the provision of such care.
              [(3) The Secretary shall supervise and evaluate the
            mental health technicians in the training program.
              [(4) The Secretary shall ensure that the program
            established pursuant to this subsection involves the
            utilization and promotion of the traditional Indian
            health care and treatment practices of the Indian
            tribes to be served.
        [(h) Mental health research
        [The Secretary, acting through the Service and in
    consultation with the National Institute of Mental Health,
    shall enter into contracts with, or make grants to, appropriate
    institutions for the conduct of research on the incidence and
    prevalence of mental disorders among Indians on Indian
    reservations and in urban areas. Research priorities under this
    subsection shall include--
              [(1) the inter-relationship and inter-dependence of
            mental disorders with alcoholism, suicide, homicides,
            accidents, and the incidence of family violence, and
              [(2) the development of models of prevention
            techniques.
        [The effect of the inter-relationships and
    interdependencies referred to in paragraph (1) on children, and
    the development of prevention techniques under paragraph (2)
    applicable to children, shall be emphasized.
        [(i) Facilities assessment
        [Within one year after November 28, 1990, the Secretary,
    acting through the Service, shall make an assessment of the
    need for inpatient mental health care among Indians and the
    availability and cost of inpatient mental health facilities
    which can meet such need. In making such assessment, the
    Secretary shall consider the possible conversion of existing,
    under-utilized service hospital beds into psychiatric units to
    meet such need.
        [(j) Annual report
        [The Service shall develop methods for analyzing and
    evaluating the overall status of mental health programs and
    services for Indians and shall submit to the President, for
    inclusion in each report required to be transmitted to the
    Congress under section 1671 of this title, a report on the
    mental health status of Indians which shall describe the
    progress being made to address mental health problems of Indian
    communities.
        [(k) Mental health demonstration grant program
              [(1) The Secretary, acting through the Service, is
            authorized to make grants to Indian tribes and inter-
            tribal consortia to pay 75 percent of the cost of
            planning, developing, and implementing programs to
            deliver innovative community-based mental health
            services to Indians. The 25 percent tribal share of
            such cost may be provided in cash or through the
            provision of property or services.
              [(2) The Secretary may award a grant for a project
            under paragraph (1) to an Indian tribe or inter-tribal
            consortium which meets the following criteria:
                      [(A) The project will address significant
                    unmet mental health needs among Indians.
                      [(B) The project will serve a significant
                    number of Indians.
                      [(C) The project has the potential to deliver
                    services in an efficient and effective manner.
                      [(D) The tribe or consortium has the
                    administrative and financial capability to
                    administer the project.
                      [(E) The project will deliver services in a
                    manner consistent with traditional Indian
                    healing and treatment practices.
                      [(F) The project is coordinated with, and
                    avoids duplication of, existing services.
              [(3) For purposes of this subsection, the Secretary
            shall, in evaluating applications for grants for
            projects to be operated under any contract entered into
            with the Service under the Indian Self-Determination
            Act [25 U.S.C.A. Sec. 450f et seq.], use the same
            criteria that the Secretary uses in evaluating any
            other application for such a grant.
              [(4) The Secretary may only award one grant under
            this subsection with respect to a service area until
            the Secretary has awarded grants for all service areas
            with respect to which the Secretary receives
            applications during the application period, as
            determined by the Secretary, which meet the criteria
            specified in paragraph (2).
              [(5) Not later than 180 days after the close of the
            term of the last grant awarded pursuant to this
            subsection, the Secretary shall submit to the Congress
            a report evaluating the effectiveness of the innovative
            community-based projects demonstrated pursuant to this
            subsection. Such report shall include findings and
            recommendations, if any, relating to the reorganization
            of the programs of the Service for delivery of mental
            health services to Indians.
              [(6) Grants made pursuant to this section may be
            expended over a period of three years and no grant may
            exceed $1,000,000 for the fiscal years involved.
        [(l) Licensing requirement for mental health care workers
        [Any person employed as a psychologist, social worker, or
    marriage and family therapist for the purpose of providing
    mental health care services to Indians in a clinical setting
    under the authority of this chapter or through a contract
    pursuant to the Indian Self-Determination Act [25 U.S.C.A.
    Sec. 450f et seq.] shall--
              [(1) in the case of a person employed as a
            psychologist, be licensed as a clinical psychologist or
            working under the direct supervision of a licensed
            clinical psychologist;
              [(2) in the case of a person employed as a social
            worker, be licensed as a social worker or working under
            the direct supervision of a licensed social worker; or
              [(3) in the case of a person employed as a marriage
            and family therapist, be licensed as a marriage and
            family therapist or working under the direct
            supervision of a licensed marriage and family
            therapist.
        [(m) Intermediate adolescent mental health services
              [(1) The Secretary, acting through the Service, may
            make grants to Indian tribes and tribal organizations
            to provide intermediate mental health services to
            Indian children and adolescents, including--
                      [(A) inpatient and outpatient services;
                      [(B) emergency care;
                      [(C) suicide prevention and crisis
                    intervention; and
                      [(D) prevention and treatment of mental
                    illness, and dysfunctional and self-destructive
                    behavior, including child abuse and family
                    violence.
              [(2) Funds provided under this subsection may be
            used--
                      [(A) to construct or renovate an existing
                    health facility to provide intermediate mental
                    health services;
                      [(B) to hire mental health professionals;
                      [(C) to staff, operate, and maintain an
                    intermediate mental health facility, group
                    home, or youth shelter where intermediate
                    mental health services are being provided; and
                      [(D) to make renovations and hire appropriate
                    staff to convert existing hospital beds into
                    adolescent psychiatric units.
              [(3) Funds provided under this subsection may not be
            used for the purposes described in section 1625o(b)(1)
            of this title.
              [(4) An Indian tribe or tribal organization receiving
            a grant under this subsection shall ensure that
            intermediate adolescent mental health services are
            coordinated with other tribal, Service, and Bureau of
            Indian Affairs mental health, alcohol and substance
            abuse, and social services programs on the reservation
            of such tribe or tribal organization.
              [(5) The Secretary shall establish criteria for the
            review and approval of applications for grants made
            pursuant to this subsection.
              [(6) There are authorized to be appropriated to carry
            out this section $10,000,000 for fiscal year 1993 and
            such sums as may be necessary for each of the fiscal
            years 1994, 1995, 1996, 1997, 1998, 1999, and 2000.
        (d) Use of Funds.--This funding may be used for both
    clinical and nonclinical research.

    [Sec. 1621i. Managed care feasibility study]

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

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

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

    SEC. 207. MAMMOGRAPHY AND OTHER CANCER SCREENING.

    [Sec. 1621k. Coverage of screening mammography]

        The Secretary, acting through the Service or Tribal Health
    Programs, shall provide for screening as follows:
              [The Secretary, through the Service, shall provide
            for screening] (1) Screening mammography (as defined in
            section 1861(jj) of the Social Security Act [[42
            U.S.C.A. Sec. 1395x(jj)]]) for Indian [and urban Indian
            women 35 years of age or older at a frequency,
            determined by the Secretary (in consultation with the
            Director of the National Cancer Institute),] women at a
            frequency appropriate to such women under accepted and
            appropriate national standards, and under such terms
            and conditions as are consistent with standards
            established by the Secretary to [assure] ensure the
            safety and accuracy of screening mammography under part
            B of title XVIII of [the Social Security Act [42
            U.S.C.A. Sec. 1395j et seq.].] such Act.
              (2) Other cancer screening that receives an A or B
            rating as recommended by the United States Preventive
            Services Task Force established under section 915(a)(1)
            of the Public Health Service Act (42 U.S.C. 299b-
            4(a)(1)). The Secretary shall ensure that screening
            provided for under this paragraph complies with the
            recommendations of the Task Force with respect to--
                      (A) frequency;
                      (B) the population to be served;
                      (C) the procedure or technology to be used;
                      (D) evidence of effectiveness; and
                      (E) other matters that the Secretary
                    determines appropriate.

    SEC. 208. PATIENT TRAVEL COSTS.

        (a) Definition of Qualified Escort.--In this section, the
    term `qualified escort' means--
              (1) an adult escort (including a parent, guardian, or
            other family member) who is required because of the
            physical or mental condition, or age, of the applicable
            patient;
              (2) a health professional for the purpose of
            providing necessary medical care during travel by the
            applicable patient; or

    [Sec. 1621l. Patient travel costs]

              (3) other escorts, as the Secretary or applicable
            Indian Health Program determines to be appropriate.
        [(a) The Secretary, acting through the Service, shall
    provide funds for the following patient travel costs] (b)
    Provision of Funds.--The Secretary, acting through the Service
    and Tribal Health Programs, is authorized to provide funds for
    the following patient travel costs, including qualified
    escorts, associated with receiving health care services
    provided (either through direct or contract care or through
    [contracts entered into pursuant to the Indian Self-
    Determination Act [25 U.S.C.A. Sec. 450f et seq.]) under this
    Act--] a contract or compact under the Indian Self-
    Determination and Education Assistance Act (25 U.S.C. 450 et
    seq.)) under this Act--
              (1) emergency air transportation[;] and [(2)
            nonemergency] non-emergency air transportation where
            ground transportation is infeasible[.];
        [(b) There are authorized to be appropriated to carry out
    this section $15,000,000 for fiscal year 1993 and such sums as
    may be necessary for each of the fiscal years 1994, 1995, 1996,
    1997, 1998, 1999, and 2000.]
              (2) transportation by private vehicle (where no other
            means of transportation is available), specially
            equipped vehicle, and ambulance; and
              (3) transportation by such other means as may be
            available and required when air or motor vehicle
            transportation is not available.

    [Sec. 1621m. Epidemiology centers]

    SEC. 209. EPIDEMIOLOGY CENTERS.

        (a)[(1)] Establishment of Centers.--The Secretary shall
    establish an epidemiology center in each Service [area] Area to
    carry out the functions described in [paragraph (3).]
    subsection (b). Any new center established after the date of
    enactment of the Indian Health Care Improvement Act Amendments
    of 2007 may be operated under a grant authorized by subsection
    (d), but funding under such a grant shall not be divisible.
              [(2) To assist such centers in carrying out such
            functions, the Secretary shall perform the following:
                      [(A) In consultation with the Centers for
                    Disease Control and Indian tribes, develop sets
                    of data (which to the extent practicable, shall
                    be consistent with the uniform data sets used
                    by the States with respect to the year 2000
                    health objectives) for uniformly defining
                    health status for purposes of the objectives
                    specified in section 1602(b) of this title.
                    Such sets shall consist of one or more
                    categories of information. The Secretary shall
                    develop formats for the uniform collecting and
                    reporting of information on such categories.
                      [(B) Establish and maintain a system for
                    monitoring the progress made toward meeting
                    each of the health status objectives described
                    in section 1602(b) of this title.
              [(3) In consultation with Indian tribes and urban
            Indian communities, each area epidemiology center
            established under this subsection shall, with respect
            to such area--
        (b) Functions of Centers.--In consultation with and upon
    the request of Indian Tribes, Tribal Organizations, and Urban
    Indian Organizations, each Service Area epidemiology center
    established under this section shall, with respect to such
    Service Area--
            [A] (1) collect data relating to, and monitor progress
            made toward meeting, each of the health status
            objectives [described in section 1602(b) of this title
            using the data sets and monitoring system developed by
            the Secretary pursuant to paragraph (2);] of the
            Service, the Indian Tribes, Tribal Organizations, and
            Urban Indian Organizations in the Service Area;
              [(B)](2) evaluate existing delivery systems, data
            systems, and other systems that impact the improvement
            of Indian health;
              [(C)](3) assist [tribes and urban Indian communities]
            Indian Tribes, Tribal Organizations, and Urban Indian
            Organizations in identifying their highest priority
            health status objectives and the services needed to
            achieve such objectives, based on epidemiological data;
              [(D)](4) make recommendations for the targeting of
            services needed by [tribal, urban, and other Indian
            communities] the populations served;
              [(E)](5) make recommendations to improve health care
            delivery systems for Indians and [urban] Urban Indians;
              [(F) work cooperatively with tribal providers of
            health and social services in order to avoid
            duplication of existing services; and]
              [(G)] (6) provide requested technical assistance to
            Indian [tribes and urban Indian organizations] Tribes,
            Tribal Organizations, and Urban Indian Organizations in
            the development of local health service priorities and
            incidence and prevalence rates of disease and other
            illness in the community[.]; and
              [(4) Epidemiology centers established under this
            subsection shall be subject to the provisions of the
            Indian Self-Determination Act (25 U.S.C. 450f et
            seq.).]
              (7) provide disease surveillance and assist Indian
            Tribes, Tribal Organizations, and Urban Indian
            Organizations to promote public health.
        [(5)] (c) Technical Assistance.--The [director] Director of
    the Centers for Disease Control and Prevention shall provide
    technical assistance to the centers in carrying out the
    requirements of this [subsection] section.
              [(6) The Service shall assign one epidemiologist from
            each of its area offices to each area epidemiology
            center to provide such center with technical assistance
            necessary to carry out this subsection.]
        (d) Grants for Studies.--
              [(b)] (1) In general.--The Secretary may make grants
            to Indian [tribes, tribal organizations] Tribes, Tribal
            Organizations, Urban Indian Organizations, and eligible
            intertribal consortia [or Indian organizations] to
            conduct epidemiological studies of Indian communities.
              [(2)] (2) Eligible intertribal consortia.--An
            intertribal [consortia or Indian organization]
            consortium is eligible to receive a grant under this
            subsection if--
                      [(A) it] (A) the intertribal consortium is
                    incorporated for the primary purpose of
                    improving Indian health; and
                      [(B) it] (B) the intertribal consortium is
                    representative of the [tribes] Indian Tribes or
                    urban Indian communities in which [it] the
                    intertribal consortium is located.
              (3) Applications.--An application for a grant under
            this subsection shall be submitted in such manner and
            at such time as the Secretary shall prescribe.
              [(4) Applicants for grants] (4) Requirements.--An
            applicant for a grant under this subsection shall--
                      (A) demonstrate the technical,
                    administrative, and financial expertise
                    necessary to carry out the functions described
                    in paragraph (5);
                      (B) consult and cooperate with providers of
                    related health and social services in order to
                    avoid duplication of existing services; and
                      (C) demonstrate cooperation from Indian
                    [tribes] Tribes or [urban] Urban Indian
                    [organizations] Organizations in the area to be
                    served.
              (5) Use of funds.--A grant awarded under paragraph
            (1) may be used [to]--
                      (A) to carry out the functions described in
                    subsection ([a]b);
                      [(3) of this section;] (B) to provide
                    information to and consult with tribal leaders,
                    urban Indian community leaders, and related
                    health staff[,] on health care and health
                    [services]service management issues; and
                      (C) [provide,] in collaboration with [tribes]
                    Indian Tribes, Tribal Organizations, and urban
                    Indian communities, to provide the Service with
                    information regarding ways to improve the
                    health status of [Indian people] Indians.
              [(6) There are authorized to be appropriated to carry
            out the purposes of this subsection not more than
            $12,000,000 for fiscal year 1993 and such sums as may
            be necessary for each of the fiscal years 1994, 1995,
            1996, 1997, 1998, 1999, and 2000.]
        (e) Access to Information.--An epidemiology center operated
    by a grantee pursuant to a grant awarded under subsection (d)
    shall be treated as a public health authority for purposes of
    the Health Insurance Portability and Accountability Act of 1996
    (Public Law 104-191; 110 Stat. 2033), as such entities are
    defined in part 164.501 of title 45, Code of Federal
    Regulations (or a successor regulation). The Secretary shall
    grant such grantees access to and use of data, data sets,
    monitoring systems, delivery systems, and other protected
    health information in the possession of the Secretary.

    [Sec. 1621n. Comprehensive school health education programs]

    SEC. 210. COMPREHENSIVE SCHOOL HEALTH EDUCATION PROGRAMS.

        [(a) Award of grants
        [The] (a) Funding for Development of Programs.--In addition
    to carrying out any other program for health promotion or
    disease prevention, the Secretary, acting through the Service
    [and in consultation with the Secretary of the Interior, may],
    is authorized to award grants to Indian [tribes] Tribes, Tribal
    Organizations, and Urban Indian Organizations to develop
    comprehensive school health education programs for children
    from [preschool] pre-school through grade 12 in schools
    [located on] for the benefit of Indian [reservations.] and
    Urban Indian children.
        (b) Use of [grantsGrants] Grant Funds.--A grant awarded
    under this section may be used [to--] for purposes which may
    include, but are not limited to, the following:
              [(1) develop health education curricula;]
              (1) Developing health education materials both for
            regular school programs and afterschool programs.
              (2) [train] Training teachers in comprehensive school
            health education [curricula;] materials.
              (3) [integrate] Integrating school-based, community-
            based, and other public and private health promotion
            efforts[;].
              (4) [encourage] Encouraging healthy, tobacco-free
            school environments[;].
              (5) [coordinate] Coordinating school-based health
            programs with existing services and programs available
            in the community[;].
              (6) [develop] Developing school programs on nutrition
            education, personal health, oral health, and
            fitness[;].
              [(7) develop mental] (7) Developing behavioral health
            wellness programs[;].
              (8) [develop] Developing chronic disease prevention
            programs[;].
              (9) [develop] Developing substance abuse prevention
            programs[;].
              (10) [develop accident] Developing injury prevention
            and safety education programs[;].
              (11) [develop] Developing activities for the
            prevention and control of communicable diseases[; and].
              (12) [develop] Developing community and environmental
            health education programs that include traditional
            health care practitioners.
              (13) Violence prevention.
              (14) Such other health issues as are appropriate.
        (c) Technical Assistance [The].--Upon request, the
    Secretary, acting through the Service, shall provide technical
    assistance to Indian [tribes] Tribes, Tribal Organizations, and
    Urban Indian Organizations in the development of comprehensive
    health education plans[,] and the dissemination of
    comprehensive health education materials and information on
    existing health programs and resources.
        (d) Criteria for [review and approval of applications. The
    Secretary] Review and Approval of Applications._The Secretary,
    acting through the Service, and in consultation with Indian
    Tribes, Tribal Organizations, and Urban Indian Organizations,
    shall establish criteria for the review and approval of
    applications for grants [made pursuant to this section.]
    awarded under this section.
        (e) [Report] Development of [recipient]
        [Recipients of grants under this section shall submit to
    the Secretary an annual report on activities undertaken with
    funds provided under this section. Such reports shall include a
    statement of--
              [(1) the number of preschools, elementary schools,
            and secondary schools served;
              [(2) the number of students served;
              [(3) any new curricula established with funds
            provided under this section;
              [(4) the number of teachers trained in the health
            curricula; and
              [(5) the involvement of parents, members of the
            community, and community health workers in programs
            established with funds provided under this section.]
        [(f)] Program [development] for BIA-Funded Schools.--
              (1) In general.--The Secretary of the Interior,
            acting through the Bureau of Indian Affairs and in
            cooperation with the Secretary, acting through the
            Service, and affected Indian Tribes and Tribal
            Organizations, shall develop a comprehensive school
            health education program for children from preschool
            through grade 12 in schools [operated] for which
            support is provided by the Bureau of Indian Affairs.
              [(2) Such program shall include--]
              (2) Requirements for programs._Such programs shall
            include--
                      (A) school programs on nutrition education,
                    personal health, oral health, and fitness;
                      (B) [mental] behavioral health wellness
                    programs;
                      (C) chronic disease prevention programs;
                      (D) substance abuse prevention programs;
                      (E) [accident] injury prevention and safety
                    education programs; and
                      (F) activities for the prevention and control
                    of communicable diseases.
              [(3) The Secretary of the Interior shall--]
              (3) Duties of the secretary._The Secretary of the
            Interior shall--
                      [(A) provide training to teachers in
                    comprehensive school health education
                    [curricula;] materials;
                      (B) ensure the integration and coordination
                    of school-based programs with existing services
                    and health programs available in the community;
                    and
                      (C) encourage healthy, tobacco-free school
                    environments.
        [(g) Authorization of appropriations
        [There are authorized to be appropriated to carry out this
    section $15,000,000 for fiscal year 1993 and such sums as may
    be necessary for each of the fiscal years 1994, 1995, 1996,
    1997, 1998, 1999, and 2000.

    [Sec. 1621o. Indian youth grant program]

    SEC. 211. INDIAN YOUTH PROGRAM.

        [(a) Grants]
        (a) Program Authorized._The Secretary, acting through the
    Service, is authorized to [make] establish and administer a
    program to provide grants to Indian [tribes, tribal
    organizations, and urban Indian organizations] Tribes, Tribal
    Organizations, and Urban Indian Organizations for innovative
    mental and physical disease prevention and health promotion and
    treatment programs for Indian and Urban Indian preadolescent
    and adolescent youths.
        (b) Use of [funds] Funds.--
              (1) Allowable Uses.--Funds made available under this
            section may be used to--
                      (A) develop prevention and treatment programs
                    for Indian youth which promote mental and
                    physical health and incorporate cultural
                    values, community and family involvement, and
                    traditional [healers] health care
                    practitioners; and
                      (B) develop and provide community training
                    and education.
              (2) Prohibited Use.--Funds made available under this
            section may not be used to provide services described
            in section [1621h(m) of this title.] 707(c).
        [(c) Models for delivery of comprehensive health care
    services
        [The]
        (c) Duties of the Secretary[shall].--The Secretary shall--
              (1) disseminate to Indian [tribes] Tribes, Tribal
            Organizations, and Urban Indian Organizations
            information regarding models for the delivery of
            comprehensive health care services to Indian and
            [urban] Urban Indian adolescents;
              (2) encourage the implementation of such models; and
              (3) at the request of an Indian [tribe] Tribe, Tribal
            Organization, or Urban Indian Organization, provide
            technical assistance in the implementation of such
            models.
        (d) Criteria for [the review and approval of applications]
    Review and Approval of Applications.--The Secretary, in
    consultation with Indian Tribes, Tribal Organizations, and
    Urban Indian Organizations, shall establish criteria for the
    review and approval of applications or proposals under this
    section.
        [(e) Authorization of appropriations
        [There are authorized to be appropriated to carry out this
    section $5,000,000 for fiscal year 1993 and such sums as may be
    necessary for each of the fiscal years 1994, 1995, 1996, 1997,
    1998, 1999, and 2000.

    [Sec. 1621p. American Indians Into Psychology Program

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

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

    SEC. 212. PREVENTION, CONTROL, AND ELIMINATION OF COMMUNICABLE AND
                        INFECTIOUS DISEASES.

        [(a) Grants]
        (a) Grants Authorized.--The Secretary, acting through the
    Service, and after consultation with the Centers for Disease
    Control and Prevention, may make grants [to Indian tribes and
    tribal organizations for--] available to Indian Tribes, Tribal
    Organizations, and Urban Indian Organizations for the
    following:
              [(1) projects for the prevention, control, and
            elimination of tuberculosis;
              [(2) public information and education programs for
            the prevention, control, and elimination of
            tuberculosis; and]
              (1) Projects for the prevention, control, and
            elimination of communicable and infectious diseases,
            including tuberculosis, hepatitis, HIV, respiratory
            syncytial virus, hanta virus, sexually transmitted
            diseases, and H. Pylori.
              (2) Public information and education programs for the
            prevention, control, and elimination of communicable
            and infectious diseases.
              (3) [education] Education, training, and clinical
            skills improvement activities in the prevention,
            control, and elimination of [tuberculosis] communicable
            and infectious diseases for health professionals,
            including allied health professionals.
              (4) Demonstration projects for the screening,
            treatment, and prevention of hepatitis C virus (HCV).
        (b) Application [for grant] Required.--The Secretary may
    [make a grant] provide funding under subsection (a) [of this
    section] only if an application [for the grant] or proposal for
    funding is submitted to the Secretary [and the application is
    in such form, is made in such manner, and contains the
    assurances required by subsection (c) of this section and such
    other agreements, assurances, and information as the Secretary
    may require.].
        [(c) Eligibility for grant
        [To be eligible for a grant under subsection (a) of this
    section, an applicant must provide assurances satisfactory to
    the Secretary that--]
              [(1) the applicant will coordinate its activities for
            the prevention, control, and elimination of
            tuberculosis with activities of] (c) Coordination With
            Health Agencies.--Indian Tribes, Tribal Organizations,
            and Urban Indian Organizations receiving funding under
            this section are encouraged to coordinate their
            activities with the Centers for Disease Control[,] and
            Prevention and State and local health agencies[; and].
              [(2) the applicant will submit to the Secretary an
            annual report on its activities for the prevention,
            control, and elimination of tuberculosis.
        [(d) Duty of Secretary]
        (d) Technical Assistance; Report._In carrying out this
    section, the Secretary--
              [(1) shall establish criteria for the review and
            approval of applications for grants under subsection
            (a) of this section, including requirement of public
            health qualifications of applicants;
              [(2) shall, subject to available appropriations, make
            at least one grant under subsection (a) of this section
            within each area office;
              [(3] (1) may, at the request of an Indian [tribe or
            tribal organization] Tribe, Tribal Organization, or
            Urban Indian Organization, provide technical
            assistance; and
              [(4] (2) shall prepare and submit a report to [the
            Committee on Energy and Commerce and the Committee on
            Natural Resources of the House and the Committee on
            Indian Affairs of the Senate not later than February 1,
            1994, and biennially thereafter,] Congress biennially
            on the use of funds under this section and on the
            progress made toward the prevention, control, and
            elimination of [tuberculosis among Indian tribes and
            tribal organizations.] communicable and infectious
            diseases among Indians and Urban Indians.
        [(e) Reduction of amount of grant
        [The Secretary may, at the request of a recipient of a
    grant under subsection (a) of this section, reduce the amount
    of such grant by--
              [(1) the fair market value of any supplies or
            equipment furnished the grant recipient; and
              [(2) the amount of the pay, allowances, and travel
            expenses of any officer or employee of the Government
            when detailed to the grant recipient and the amount of
            any other costs incurred in connection with the detail
            of such officer or employee,
            when the furnishing of such supplies or equipment or
            the detail of such an officer or employee is for the
            convenience of and at the request of such grant
            recipient and for the purpose of carrying out a program
            with respect to which the grant under subsection (a) of
            this section is made. The amount by which any such
            grant is so reduced shall be available for payment by
            the Secretary of the costs incurred in furnishing the
            supplies or equipment, or in detailing the personnel,
            on which the reduction of such grant is based, and such
            amount shall be deemed as part of the grant and shall
            be deemed to have been paid to the grant recipient.]

    SEC. 213. OTHER AUTHORITY FOR PROVISION OF SERVICES.

        (a) Funding Authorized.--The Secretary, acting through the
    Service, Indian Tribes, and Tribal Organizations, may provide
    funding under this Act to meet the objectives set forth in
    section 3 of this Act through health care-related services and
    programs not otherwise described in this Act, including--
              (1) hospice care;
              (2) assisted living;
              (3) long-term care; and
              (4) home- and community-based services.
        (b) Terms and Conditions.--
              (1) In general.--Any service provided under this
            section shall be in accordance with such terms and
            conditions as are consistent with accepted and
            appropriate standards relating to the service,
            including any licensing term or condition under this
            Act.
              (2) Standards.--
                      (A) In general.--The Secretary may establish,
                    by regulation, the standards for a service
                    provided under this section, provided that such
                    standards shall not be more stringent than the
                    standards required by the State in which the
                    service is provided.
                      (B) Use of state standards.--If the Secretary
                    does not, by regulation, establish standards
                    for a service provided under this section, the
                    standards required by the State in which the
                    service is or will be provided shall apply to
                    such service.
                      (C) Indian tribes.--If a service under this
                    section is provided by an Indian Tribe or
                    Tribal Organization pursuant to the Indian
                    Self-Determination and Education Assistance Act
                    (25 U.S.C. 450 et seq.), the verification by
                    the Secretary that the service meets any
                    standards required by the State in which the
                    service is or will be provided shall be
                    considered to meet the terms and conditions
                    required under this subsection.
              (3) Eligibility.--The following individuals shall be
            eligible to receive long-term care under this section:
                      (A) Individuals who are unable to perform a
                    certain number of activities of daily living
                    without assistance.
                      (B) Individuals with a mental impairment,
                    such as dementia, Alzheimer's disease, or
                    another disabling mental illness, who may be
                    able to perform activities of daily living
                    under supervision.
                      (C) Such other individuals as an applicable
                    Indian Health Program determines to be
                    appropriate.
        (c) Definitions.--For the purposes of this section, the
    following definitions shall apply:
              (1) The term ``home- and community-based services''
            means 1 or more of the services specified in paragraphs
            (1) through (9) of section 1929(a) of the Social
            Security Act (42 U.S.C. 1396t(a)) (whether provided by
            the Service or by an Indian Tribe or Tribal
            Organization pursuant to the Indian Self-Determination
            and Education Assistance Act (25 U.S.C. 450 et seq.))
            that are or will be provided in accordance with the
            standards described in subsection (b).
              (2) The term ``hospice care'' means the items and
            services specified in subparagraphs (A) through (H) of
            section 1861(dd)(1) of the Social Security Act (42
            U.S.C. 1395x(dd)(1)), and such other services which an
            Indian Tribe or Tribal Organization determines are
            necessary and appropriate to provide in furtherance of
            this care.
        (d) Authorization of Convenient Care Services.--The
    Secretary, acting through the Service, Indian Tribes, and
    Tribal Organizations, may also provide funding under this Act
    to meet the objectives set forth in section 3 of this Act for
    convenient care services programs pursuant to section
    306(c)(2)(A).

    SEC. 214. INDIAN WOMEN'S HEALTH CARE.

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

    SEC. 215. ENVIRONMENTAL AND NUCLEAR HEALTH HAZARDS.

        (a) Studies and Monitoring.--The Secretary and the Service
    shall conduct, in conjunction with other appropriate Federal
    agencies and in consultation with concerned Indian Tribes and
    Tribal Organizations, studies and ongoing monitoring programs
    to determine trends in the health hazards to Indian miners and
    to Indians on or near reservations and Indian communities as a
    result of environmental hazards which may result in chronic or
    life threatening health problems, such as nuclear resource
    development, petroleum contamination, and contamination of
    water source and of the food chain. Such studies shall
    include--
              (1) an evaluation of the nature and extent of health
            problems caused by environmental hazards currently
            exhibited among Indians and the causes of such health
            problems;
              (2) an analysis of the potential effect of ongoing
            and future environmental resource development on or
            near reservations and Indian communities, including the
            cumulative effect over time on health;
              (3) an evaluation of the types and nature of
            activities, practices, and conditions causing or
            affecting such health problems, including uranium
            mining and milling, uranium mine tailing deposits,
            nuclear power plant operation and construction, and
            nuclear waste disposal; oil and gas production or
            transportation on or near reservations or Indian
            communities; and other development that could affect
            the health of Indians and their water supply and food
            chain;
              (4) a summary of any findings and recommendations
            provided in Federal and State studies, reports,
            investigations, and inspections during the 5 years
            prior to the date of enactment of the Indian Health
            Care Improvement Act Amendments of 2007 that directly
            or indirectly relate to the activities, practices, and
            conditions affecting the health or safety of such
            Indians; and
              (5) the efforts that have been made by Federal and
            State agencies and resource and economic development
            companies to effectively carry out an education program
            for such Indians regarding the health and safety
            hazards of such development.
        (b) Health Care Plans.--Upon completion of such studies,
    the Secretary and the Service shall take into account the
    results of such studies and develop health care plans to
    address the health problems studied under subsection (a). The
    plans shall include--
              (1) methods for diagnosing and treating Indians
            currently exhibiting such health problems;
              (2) preventive care and testing for Indians who may
            be exposed to such health hazards, including the
            monitoring of the health of individuals who have or may
            have been exposed to excessive amounts of radiation or
            affected by other activities that have had or could
            have a serious impact upon the health of such
            individuals; and
              (3) a program of education for Indians who, by reason
            of their work or geographic proximity to such nuclear
            or other development activities, may experience health
            problems.
        (c) Submission of Report and Plan to Congress.--The
    Secretary and the Service shall submit to Congress the study
    prepared under subsection (a) no later than 18 months after the
    date of enactment of the Indian Health Care Improvement Act
    Amendments of 2007. The health care plan prepared under
    subsection (b) shall be submitted in a report no later than 1
    year after the study prepared under subsection (a) is submitted
    to Congress. Such report shall include recommended activities
    for the implementation of the plan, as well as an evaluation of
    any activities previously undertaken by the Service to address
    such health problems.
        (d) Intergovernmental Task Force.--
              (1) Establishment; members.--There is established an
            Intergovernmental Task Force to be composed of the
            following individuals (or their designees):
                      (A) The Secretary of Energy.
                      (B) The Secretary of the Environmental
                    Protection Agency.
                      (C) The Director of the Bureau of Mines.
                      (D) The Assistant Secretary for Occupational
                    Safety and Health.
                      (E) The Secretary of the Interior.
                      (F) The Secretary of Health and Human
                    Services.
                      (G) The Assistant Secretary.
              (2) Duties.--The Task Force shall--
                      (A) identify existing and potential
                    operations related to nuclear resource
                    development or other environmental hazards that
                    affect or may affect the health of Indians on
                    or near a reservation or in an Indian
                    community; and
                      (B) enter into activities to correct existing
                    health hazards and ensure that current and
                    future health problems resulting from nuclear
                    resource or other development activities are
                    minimized or reduced.
              (3) Chairman; meetings.--The Secretary of Health and
            Human Services shall be the Chairman of the Task Force.
            The Task Force shall meet at least twice each year.
        (e) Health Services to Certain Employees.--In the case of
    any Indian who--
              (1) as a result of employment in or near a uranium
            mine or mill or near any other environmental hazard,
            suffers from a work-related illness or condition;
              (2) is eligible to receive diagnosis and treatment
            services from an Indian Health Program; and
              (3) by reason of such Indian's employment, is
            entitled to medical care at the expense of such mine or
            mill operator or entity responsible for the
            environmental hazard, the Indian Health Program shall,
            at the request of such Indian, render appropriate
            medical care to such Indian for such illness or
            condition and may be reimbursed for any medical care so
            rendered to which such Indian is entitled at the
            expense of such operator or entity from such operator
            or entity. Nothing in this subsection shall affect the
            rights of such Indian to recover damages other than
            such amounts paid to the Indian Health Program from the
            employer for providing medical care for such illness or
            condition.

    SEC. 216. ARIZONA AS A CONTRACT HEALTH SERVICE DELIVERY AREA.

        (a) In General.--For fiscal years beginning with the fiscal
    year ending September 30, 1983, and ending with the fiscal year
    ending September 30, 2016, the State of Arizona shall be
    designated as a contract health service delivery area by the
    Service for the purpose of providing contract health care
    services to members of federally recognized Indian Tribes of
    Arizona.
        (b) Maintenance of Services.--The Service shall not curtail
    any health care services provided to Indians residing on
    reservations in the State of Arizona if such curtailment is due
    to the provision of contract services in such State pursuant to
    the designation of such State as a contract health service
    delivery area pursuant to subsection (a).

    SEC. 216A. NORTH DAKOTA AND SOUTH DAKOTA AS CONTRACT HEALTH SERVICE
                        DELIVERY AREA.

        (a) In General.--Beginning in fiscal year 2003, the States
    of North Dakota and South Dakota shall be designated as a
    contract health service delivery area by the Service for the
    purpose of providing contract health care services to members
    of federally recognized Indian Tribes of North Dakota and South
    Dakota.
        (b) Limitation.--The Service shall not curtail any health
    care services provided to Indians residing on any reservation,
    or in any county that has a common boundary with any
    reservation, in the State of North Dakota or South Dakota if
    such curtailment is due to the provision of contract services
    in such States pursuant to the designation of such States as a
    contract health service delivery area pursuant to subsection
    (a).

    SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES PROGRAM.

        (a) Funding Authorized.--The Secretary is authorized to
    fund a program using the California Rural Indian Health Board
    (hereafter in this section referred to as the ``CRIHB") as a
    contract care intermediary to improve the accessibility of
    health services to California Indians.
        (b) Reimbursement Contract.--The Secretary shall enter into
    an agreement with the CRIHB to reimburse the CRIHB for costs
    (including reasonable administrative costs) incurred pursuant
    to this section, in providing medical treatment under contract
    to California Indians described in section 806(a) throughout
    the California contract health services delivery area described
    in section 218 with respect to high cost contract care cases.
        (c) Administrative Expenses.--Not more than 5 percent of
    the amounts provided to the CRIHB under this section for any
    fiscal year may be for reimbursement for administrative
    expenses incurred by the CRIHB during such fiscal year.
        (d) Limitation on Payment.--No payment may be made for
    treatment provided hereunder to the extent payment may be made
    for such treatment under the Indian Catastrophic Health
    Emergency Fund described in section 202 or from amounts
    appropriated or otherwise made available to the California
    contract health service delivery area for a fiscal year.
        (e) Advisory Board.--There is established an advisory board
    which shall advise the CRIHB in carrying out this section. The
    advisory board shall be composed of representatives, selected
    by the CRIHB, from not less than 8 Tribal Health Programs
    serving California Indians covered under this section at least
    \1/2\ of whom of whom are not affiliated with the CRIHB.

    SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE DELIVERY AREA.

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

    SEC. 219. CONTRACT HEALTH SERVICES FOR THE TRENTON SERVICE AREA.

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

    SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND TRIBAL ORGANIZATIONS.

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

    SEC. 221. LICENSING.

        Health care professionals employed by a Tribal Health
    Program shall, if licensed in any State, be exempt from the
    licensing requirements of the State in which the Tribal Health
    Program performs the services described in its contract or
    compact under the Indian Self-Determination and Education
    Assistance Act (25 U.S.C. 450 et seq.).

    [Sec. 1621r. Contract health services payment study]

    SEC. 222. NOTIFICATION OF PROVISION OF EMERGENCY CONTRACT HEALTH
                        SERVICES.

        [(a) Duties of Secretary
        [The Secretary, acting through the Service and in
    consultation with representatives of Indian tribes and tribal
    organizations operating contract health care programs under the
    Indian Self-Determination Act (25 U.S.C. 450f et seq.) or under
    self-governance compacts, Service personnel, private contract
    health services providers, the Indian Health Service Fiscal
    Intermediary, and other appropriate experts, shall conduct a
    study--
              [(1) to assess and identify administrative barriers
            that hinder the timely payment for services delivered
            by private contract health services providers to
            individual Indians by the Service and the Indian Health
            Service Fiscal Intermediary;
              [(2) to assess and identify the impact of such
            delayed payments upon the personal credit histories of
            individual Indians who have been treated by such
            providers; and
              [(3) to determine the most efficient and effective
            means of improving the Service's contract health
            services payment system and ensuring the development of
            appropriate consumer protection policies to protect
            individual Indians who receive authorized services from
            private contract health services providers from billing
            and collection practices, including the development of
            materials and programs explaining patients' rights and
            responsibilities.
        [(b) Functions of study
        [The study required by subsection (a) of this section
    shall--
              [(1) assess the impact of the existing contract
            health services regulations and policies upon the
            ability of the Service and the Indian Health Service
            Fiscal Intermediary to process, on a timely and
            efficient basis, the payment of bills submitted by
            private contract health services providers;
              [(2) assess the financial and any other burdens
            imposed upon individual Indians and private contract
            health services providers by delayed payments;
              [(3) survey the policies and practices of collection
            agencies used by contract health services providers to
            collect payments for services rendered to individual
            Indians;
              [(4) identify appropriate changes in Federal
            policies, administrative procedures, and regulations,
            to eliminate the problems experienced by private
            contract health services providers and individual
            Indians as a result of delayed payments; and
              [(5) compare the Service's payment processing
            requirements with private insurance claims processing
            requirements to evaluate the systemic differences or
            similarities employed by the Service and private
            insurers.
        [(c) Report to Congress
        [Not later than 12 months after October 29, 1992, the
    Secretary shall transmit to the Congress a report that
    includes--
              [(1) a detailed description of the study conducted
            pursuant to this section; and
              [(2) a discussion of the findings and conclusions of
            such study.]
        With respect to an elderly Indian or an Indian with a
    disability receiving emergency medical care or services from a
    non-Service provider or in a non-Service facility under the
    authority of this Act, the time limitation (as a condition of
    payment) for notifying the Service of such treatment or
    admission shall be 30 days.

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

    SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS.

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

    [Sec. 1621t. Demonstration of electronic claims processing]

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

    SEC. 224. LIABILITY FOR PAYMENT.

    [Sec. 1621u.]

        (a) No Patient Liability[for payment (a)].--A patient who
    receives contract health care services that are authorized by
    the Service shall not be liable for the payment of any charges
    or costs associated with the provision of such services.
        (b) Notification._[The Secretary shall notify a contract
    care provider and any patient who receives contract health care
    services authorized by the Service that such patient is not
    liable for the payment of any charges or costs associated with
    the provision of such services not later than 5 business days
    after receipt of a notification of a claim by a provider of
    contract care services.
        (c) No Recourse.--Following receipt of the notice provided
    under subsection (b), or, if a claim has been deemed accepted
    under section 223(b), the provider shall have no further
    recourse against the patient who received the services.

    SEC. 225. OFFICE OF INDIAN MEN'S HEALTH.

        (a) Establishment.--The Secretary may establish within the
    Service an office to be known as the ``Office of Indian Men's
    Health'' (referred to in this section as the ``Office'').
        (b) Director.--
              (1) In general.--The Office shall be headed by a
            director, to be appointed by the Secretary.
              (2) Duties.--The director shall coordinate and
            promote the status of the health of Indian men in the
            United States.
        (c) Report.--Not later than 2 years after the date of
    enactment of the Indian Health Care Improvement Act Amendments
    of 2007, the Secretary, acting through the director of the
    Office, shall submit to Congress a report describing--

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

              (1) any activity carried out by the director as of
            the date on which the report is prepared; and
              [There is established within the Service an Office of
            Indian Women's Health Care to oversee efforts of the
            Service to monitor and improve the quality of health
            care for Indian women of all ages through the planning
            and delivery of programs administered by the Service,
            in order to improve and enhance the treatment models of
            care for Indian women.]
              (2) any finding of the director with respect to the
            health of Indian men.

    [Sec. 1621w. Authorization of appropriations]

    SEC. 226. AUTHORIZATION OF APPROPRIATIONS.

        [Except as provided in sections 1621h(m), 1621j, 1621l,
    1621m(b)(5), 1621n, and 1621o of this title, there] There are
    authorized to be appropriated such sums as may be necessary for
    each fiscal year through fiscal year [2000 to carry out this
    subchapter] 2017 to carry out this title.

    [Sec. 1621x. Limitation on use of funds

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

                             TITLE III--FACILITIES

    [Sec. 1631. Consultation; closure of facilities; reports]

    SEC. 301. CONSULTATION; CONSTRUCTION AND RENOVATION OF FACILITIES;
                        REPORTS.

        [(a) Consultation; standards for accreditation]
        (a) Prerequisites for Expenditure of Funds._Prior to the
    expenditure of, or the making of any [firm] binding commitment
    to expend, any funds appropriated for the planning, design,
    construction, or renovation of facilities pursuant to the Act
    of November 2, 1921 (25 U.S.C. 13)[,] [popularly] (commonly
    known as the ``Snyder Act''), the Secretary, acting through the
    Service, shall--
              (1) consult with any Indian [tribe] Tribe that would
            be significantly affected by such expenditure for the
            purpose of determining and, whenever practicable,
            honoring tribal preferences concerning size, location,
            type, and other characteristics of any facility on
            which such expenditure is to be made[,]; and
              (2) ensure, whenever practicable and applicable, that
            such facility meets the construction standards of [the
            Joint Commission on Accreditation of Health Care
            Organizations] any accrediting body recognized by the
            Secretary for the purposes of the Medicare, Medicaid,
            and SCHIP programs under titles XVIII, XIX, and XXI of
            the Social Security Act by not later than 1 year after
            the date on which the construction or renovation of
            such facility is completed.
        [(b) Closure; report on proposed closure]
        (b) Closures.--
              (1) Evaluation required._Notwithstanding any other
            provision of law [other than this subsection], no
            facility operated by the Service [hospital or
            outpatient health care facility of the Service], or any
            portion of such [a hospital or] facility, may be closed
            if the Secretary has not submitted to [the Congress at
            least 1 year prior to the date such hospital or
            facility (or portion thereof) is proposed to be closed
            on evaluation of the impact of such proposed closure
            which] Congress not less than 1 year, and not more than
            2 years, before the date of the proposed closure an
            evaluation, completed not more than 2 years before the
            submission, of the impact of the proposed closure that
            specifies, in addition to other considerations--
                      (A) the accessibility of alternative health
                    care resources for the population served by
                    such [hospital or] facility;
                      (B) the cost-effectiveness of such closure;
                      (C) the quality of health care to be provided
                    to the population served by such [hospital or]
                    facility after such closure;
                      (D) the availability of contract health care
                    funds to maintain existing levels of service;
                      (E) the views of the Indian [tribes] Tribes
                    served by such [hospital or] facility
                    concerning such closure;
                      (F) the level of [utilization] use of such
                    [hospital or] facility by all eligible Indians;
                    and
                      (G) the distance between such [hospital or]
                    facility and the nearest operating Service
                    hospital.
              (2) Exception for certain temporary closures._
            Paragraph (1) shall not apply to any temporary closure
            of a facility or [of] any portion of a facility if such
            closure is necessary for medical, environmental, or
            construction safety reasons.
        [(c) Annual report on health facility priority system
              [(1) The Secretary shall submit to the President, for
            inclusion in each report required to be transmitted to
            the Congress under section 1671 of this title, a report
            which sets forth--
                      [(A) the current health facility priority
                    system of the Service,
                      [(B) the planning, design, construction, and
                    renovation needs for the 10 top-priority
                    inpatient care facilities and the 10 top-
                    priority ambulatory care facilities (together
                    with required staff quarters),
                      [(C) the justification for such order of
                    priority,
                      [(D) the projected cost of such projects, and
                      [(E) the methodology adopted by the Service
                    in establishing priorities under its health
                    facility priority system.
              [(2) In preparing each report required under
            paragraph (1) (other than the initial report), the
            Secretary shall--
                      [(A) consult with Indian tribes and tribal
                    organizations including those tribes or tribal
                    organizations operating health programs or
                    facilities under any contract entered into with
                    the Service under the Indian Self-Determination
                    Act [25 U.S.C.A. Sec. 450f et seq.], and
                      [(B) review the needs of such tribes and
                    tribal organizations for inpatient and
                    outpatient facilities, including their needs
                    for renovation and expansion of existing
                    facilities.
              [(3) For purposes of this subsection, the Secretary
            shall, in evaluating the needs of facilities operated
            under any contract entered into with the Service under
            the Indian Self-Determination Act [25 U.S.C.A.
            Sec. 450f et seq.], use the same criteria that the
            Secretary uses in evaluating the needs of facilities
            operated directly by the Service.]
        (c) Health Care Facility Priority System.--
              (1) In general.--
                      (A) Priority system.--The Secretary, acting
                    through the Service, shall maintain a health
                    care facility priority system, which--
                              (i) shall be developed in
                            consultation with Indian Tribes and
                            Tribal Organizations;
                              (ii) shall give Indian Tribes' needs
                            the highest priority;
                              (iii)(I) may include the lists
                            required in paragraph (2)(B)(ii); and
                              (II) shall include the methodology
                            required in paragraph (2)(B)(v); and
                              (III) may include such other
                            facilities, and such renovation or
                            expansion needs of any health care
                            facility, as the Service, Indian
                            Tribes, and Tribal Organizations may
                            identify; and
                              (iv) shall provide an opportunity for
                            the nomination of planning, design, and
                            construction projects by the Service,
                            Indian Tribes, and Tribal Organizations
                            for consideration under the priority
                            system at least once every 3 years, or
                            more frequently as the Secretary
                            determines to be appropriate.
                      [(4)] (B) Needs of facilities under ISDEAA
                    agreements.--The Secretary shall ensure that
                    the planning, design, construction, [and]
                    renovation, and expansion needs of Service and
                    non-Service facilities [which are the subject
                    of a contract for health services entered into
                    with the Service under] operated under
                    contracts or compacts in accordance with the
                    Indian Self-Determination and Education
                    Assistance Act [[](25 U.S.C.[A. Sec. 450f] 450
                    et seq.[]])are fully and equitably integrated
                    into the [development of the] health care
                    facility priority system.
        [(d) Funds appropriated subject to section 450f of this
    title]
                      (C) Criteria for evaluating needs.--For
                    purposes of this subsection, the Secretary, in
                    evaluating the needs of facilities operated
                    under a contract or compact under the Indian
                    Self-Determination and Education Assistance Act
                    (25 U.S.C. 450 et seq.), shall use the criteria
                    used by the Secretary in evaluating the needs
                    of facilities operated directly by the Service.
                      (D) Priority of certain projects protected.--
                    The priority of any project established under
                    the construction priority system in effect on
                    the date of enactment of the Indian Health Care
                    Improvement Act Amendments of 2007 shall not be
                    affected by any change in the construction
                    priority system taking place after that date if
                    the project--
                              (i) was identified in the fiscal year
                            2008 Service budget justification as--
                                      (I) 1 of the 10 top-priority
                                    inpatient projects;
                                      (II) 1 of the 10 top-priority
                                    outpatient projects;
                                      (III) 1 of the 10 top-
                                    priority staff quarters
                                    developments; or
                                      (IV) 1 of the 10 top-priority
                                    Youth Regional Treatment
                                    Centers;
                              (ii) had completed both Phase I and
                            Phase II of the construction priority
                            system in effect on the date of
                            enactment of such Act; or
                              (iii) is not included in clause (i)
                            or (ii) and is selected, as determined
                            by the Secretary--
                                      (I) on the initiative of the
                                    Secretary; or
                                      (II) pursuant to a request of
                                    an Indian Tribe or Tribal
                                    Organization.
              (2) Report; contents.--
                      (A) Initial comprehensive report.--
                              (i) Definitions.--In this
                            subparagraph:
                                      (I) Facilities appropriation
                                    advisory board.--The term
                                    ``Facilities Appropriation
                                    Advisory Board'' means the
                                    advisory board, comprised of 12
                                    members representing Indian
                                    tribes and 2 members
                                    representing the Service,
                                    established at the discretion
                                    of the Assistant Secretary--
                                              (aa) to provide
                                            advice and
                                            recommendations for
                                            policies and procedures
                                            of the programs funded
                                            pursuant to facilities
                                            appropriations; and
                                              (bb) to address other
                                            facilities issues.
                                      (II) Facilities needs
                                    assessment workgroup.--The term
                                    ``Facilities Needs Assessment
                                    Workgroup'' means the workgroup
                                    established at the discretion
                                    of the Assistant Secretary--
                                              (aa) to review the
                                            health care facilities
                                            construction priority
                                            system; and
                                              (bb) to make
                                            recommendations to the
                                            Facilities
                                            Appropriation Advisory
                                            Board for revising the
                                            priority system.
                              (ii) Initial report.--
                                      (I) In general.--Not later
                                    than 1 year after the date of
                                    enactment of the Indian Health
                                    Care Improvement Act Amendments
                                    of 2007, the Secretary shall
                                    submit to the Committee on
                                    Indian Affairs of the Senate
                                    and the Committee on Natural
                                    Resources of the House of
                                    Representatives a report that
                                    describes the comprehensive,
                                    national, ranked list of all
                                    health care facilities needs
                                    for the Service, Indian Tribes,
                                    and Tribal Organizations
                                    (including inpatient health
                                    care facilities, outpatient
                                    health care facilities,
                                    specialized health care
                                    facilities (such as for long-
                                    term care and alcohol and drug
                                    abuse treatment), wellness
                                    centers, staff quarters and
                                    hostels associated with health
                                    care facilities, and the
                                    renovation and expansion needs,
                                    if any, of such facilities)
                                    developed by the Service,
                                    Indian Tribes, and Tribal
                                    Organizations for the
                                    Facilities Needs Assessment
                                    Workgroup and the Facilities
                                    Appropriation Advisory Board.
                                      (II) Inclusions.--The initial
                                    report shall include--
                                              (aa) the methodology
                                            and criteria used by
                                            the Service in
                                            determining the needs
                                            and establishing the
                                            ranking of the
                                            facilities needs; and
                                              (bb) such other
                                            information as the
                                            Secretary determines to
                                            be appropriate.
                              (iii) Updates of report.--Beginning
                            in calendar year 2011, the Secretary
                            shall--
                                      (I) update the report under
                                    clause (ii) not less frequently
                                    than once every 5 years; and
                                      (II) include the updated
                                    report in the appropriate
                                    annual report under
                                    subparagraph (B) for submission
                                    to Congress under section 801.
                      (B) Annual reports.--The Secretary shall
                    submit to the President, for inclusion in the
                    report required to be transmitted to Congress
                    under section 801, a report which sets forth
                    the following:
                              (i) A description of the health care
                            facility priority system of the Service
                            established under paragraph (1).
                              (ii) Health care facilities lists,
                            which may include--
                                      (I) the 10 top-priority
                                    inpatient health care
                                    facilities;
                                      (II) the 10 top-priority
                                    outpatient health care
                                    facilities;
                                      (III) the 10 top-priority
                                    specialized health care
                                    facilities (such as long-term
                                    care and alcohol and drug abuse
                                    treatment);
                                      (IV) the 10 top-priority
                                    staff quarters developments
                                    associated with health care
                                    facilities; and
                                      (V) the 10 top-priority
                                    hostels associated with health
                                    care facilities.
                              (iii) The justification for such
                            order of priority.
                              (iv) The projected cost of such
                            projects.
                              (v) The methodology adopted by the
                            Service in establishing priorities
                            under its health care facility priority
                            system.
              (3) Requirements for preparation of reports.--In
            preparing the report required under paragraph (2), the
            Secretary shall--
                      (A) consult with and obtain information on
                    all health care facilities needs from Indian
                    Tribes, Tribal Organizations, and Urban Indian
                    Organizations; and
                      (B) review the total unmet needs of all
                    Indian Tribes, Tribal Organizations, and Urban
                    Indian Organizations for health care facilities
                    (including hostels and staff quarters),
                    including needs for renovation and expansion of
                    existing facilities.
        (d) Review of Methodology Used for Health Facilities
    Construction Priority System.--
              (1) In general.--Not later than 1 year after the
            establishment of the priority system under subsection
            (c)(1)(A), the Comptroller General of the United States
            shall prepare and finalize a report reviewing the
            methodologies applied, and the processes followed, by
            the Service in making each assessment of needs for the
            list under subsection (c)(2)(A)(ii) and developing the
            priority system under subsection (c)(1), including a
            review of--
                      (A) the recommendations of the Facilities
                    Appropriation Advisory Board and the Facilities
                    Needs Assessment Workgroup (as those terms are
                    defined in subsection (c)(2)(A)(i)); and
                      (B) the relevant criteria used in ranking or
                    prioritizing facilities other than hospitals or
                    clinics.
              (2) Submission to congress.--The Comptroller General
            of the United States shall submit the report under
            paragraph (1) to--
                      (A) the Committees on Indian Affairs and
                    Appropriations of the Senate;
                      (B) the Committees on Natural Resources and
                    Appropriations of the House of Representatives;
                    and
                      (C) the Secretary.
        (e) Funding Condition._ All funds appropriated under the
    Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the
    ``Snyder Act''), for the planning, design, construction, or
    renovation of health facilities for the benefit of [an] 1 or
    more Indian [tribe or tribes] Tribes shall be subject to the
    provisions of [section 102 of] the Indian Self-Determination
    and Education Assistance Act [(25 U.S.C.[A. Sec. 450f].] 450 et
    seq.).
        (f) Development of Innovative Approaches.--The Secretary
    shall consult and cooperate with Indian Tribes, Tribal
    Organizations, and Urban Indian Organizations in developing
    innovative approaches to address all or part of the total unmet
    need for construction of health facilities, including those
    provided for in other sections of this title and other
    approaches.

    [Sec. 1632. Safe water and sanitary waste disposal facilities]

    SEC. 302. SANITATION FACILITIES.

        [(a) Congressional findings
        [The] (a) Findings._Congress [hereby] finds [and declares
    that--] the following:
              (1) [the]The provision of [safe water supply systems
            and sanitary sewage and solid waste disposal
            systems]sanitation facilities is primarily a health
            consideration and function[;].
              (2) Indian people suffer an inordinately high
            incidence of disease, injury, and illness directly
            attributable to the absence or inadequacy of [such
            systems;]sanitation facilities.
              (3) [the]The long-term cost to the United States of
            treating and curing such disease, injury, and illness
            is substantially greater than the short-term cost of
            providing [such systems]sanitation facilities and other
            preventive health measures[;].
              (4) [many]Many Indian homes and Indian communities
            still lack [safe water supply systems and sanitary
            sewage and solid waste disposal systems; and]sanitation
            facilities.
              (5) [it]It is in the interest of the United States,
            and it is the policy of the United States, that all
            Indian communities and Indian homes, new and existing,
            be provided with [safe and adequate water supply
            systems and sanitary sewage waste disposal systems as
            soon as possible]sanitation facilities.
        [(b) Authority; assistance; transfer of funds]
        [(1)](b) Facilities and Services.--In furtherance of the
    findings [and declarations] made in subsection (a) [of this
    section] , Congress reaffirms the primary responsibility and
    authority of the Service to provide the necessary sanitation
    facilities and services as provided in section [2004a of Title
    42. (2) The] 7 of the Act of August 5, 1954 (42 U.S.C. 2004a).
    Under such authority, the Secretary, acting through the
    Service, is authorized to provide [under section 2004a of Title
    42--] the following:
              [(A) financial](1) Financial and technical assistance
            to Indian [tribes and]Tribes, Tribal Organizations, and
            Indian communities in the establishment, training, and
            equipping of utility organizations to operate and
            maintain [Indian sanitation facilities;]sanitation
            facilities, including the provision of existing plans,
            standard details, and specifications available in the
            Department, to be used at the option of the Indian
            Tribe, Tribal Organization, or Indian community.
              [(B)] (2) [ongoing]Ongoing technical assistance and
            training to Indian Tribes, Tribal Organizations, and
            Indian communities in the management of utility
            organizations which operate and maintain sanitation
            facilities[; and].
              [(C)](3) Priority funding for operation and
            maintenance assistance for, and emergency repairs to,
            [tribal] sanitation facilities operated by an Indian
            Tribe, Tribal Organization or Indian community when
            necessary to avoid [a] an imminent health [hazard]
            threat or to protect the [Federal] investment in
            sanitation facilities[.] and the investment in the
            health benefits gained through the provision of
            sanitation facilities.
        [(3)](c) Funding._Notwithstanding any other provision of
    law--
                      [(A) the Secretary of Housing and Urban
                    Affairs is authorized to transfer funds
                    appropriated under the Housing and Community
                    Development Act of 1974 (42 U.S.C. 5301, et
                    seq.) to the Secretary of Health and Human
                    Services; and]
              (1) the Secretary of Housing and Urban Development is
            authorized to transfer funds appropriated under the
            Native American Housing Assistance and Self-
            Determination Act of 1996 (25 U.S.C. 4101 et seq.) to
            the Secretary of Health and Human Services;
              [(B)](2) the Secretary of Health and Human Services
            is authorized to accept and use such funds for the
            purpose of providing sanitation facilities and services
            for Indians under section [2004a of Title 42.] 7 of the
            Act of August 5, 1954 (42 U.S.C. 2004a);
        [(c) 10-year plan
        [Beginning in fiscal year 1990, the Secretary, acting
    through the Service, shall develop and begin implementation of
    a 10-year plan to provide safe water supply and sanitation
    sewage and solid waste disposal facilities to existing Indian
    homes and communities and to new and renovated Indian homes
        [(d) Tribal capability]
              (3) unless specifically authorized when funds are
            appropriated, the Secretary shall not use funds
            appropriated under section 7 of the Act of August 5,
            1954 (42 U.S.C. 2004a), to provide sanitation
            facilities to new homes constructed using funds
            provided by the Department of Housing and Urban
            Development;
              (4) the Secretary of Health and Human Services is
            authorized to accept from any source, including Federal
            and State agencies, funds for the purpose of providing
            sanitation facilities and services and place these
            funds into contracts or compacts under the Indian Self-
            Determination and Education Assistance Act (25 U.S.C.
            450 et seq.);
              (5) except as otherwise prohibited by this section,
            the Secretary may use funds appropriated under the
            authority of section 7 of the Act of August 5, 1954 (42
            U.S.C. 2004a), to fund up to 100 percent of the amount
            of an Indian Tribe's loan obtained under any Federal
            program for new projects to construct eligible
            sanitation facilities to serve Indian homes;
              (6) except as otherwise prohibited by this section,
            the Secretary may use funds appropriated under the
            authority of section 7 of the Act of August 5, 1954 (42
            U.S.C. 2004a) to meet matching or cost participation
            requirements under other Federal and non-Federal
            programs for new projects to construct eligible
            sanitation facilities;
              (7) all Federal agencies are authorized to transfer
            to the Secretary funds identified, granted, loaned, or
            appropriated whereby the Department's applicable
            policies, rules, and regulations shall apply in the
            implementation of such projects;
              (8) the Secretary of Health and Human Services shall
            enter into interagency agreements with Federal and
            State agencies for the purpose of providing financial
            assistance for sanitation facilities and services under
            this Act;
              (9) the Secretary of Health and Human Services shall,
            by regulation, establish standards applicable to the
            planning, design, and construction of sanitation
            facilities funded under this Act; and
              (10) the Secretary of Health and Human Services is
            authorized to accept payments for goods and services
            furnished by the Service from appropriate public
            authorities, nonprofit organizations or agencies, or
            Indian Tribes, as contributions by that authority,
            organization, agency, or tribe to agreements made under
            section 7 of the Act of August 5, 1954 (42 U.S.C.
            2004a), and such payments shall be credited to the same
            or subsequent appropriation account as funds
            appropriated under the authority of section 7 of the
            Act of August 5, 1954 (42 U.S.C. 2004a).
        (d) Certain Capabilities Not Prerequisite.--The financial
    and technical capability of an Indian [tribe or] Tribe, Tribal
    Organization, or Indian community to safely operate, manage,
    and maintain a sanitation facility shall not be a prerequisite
    to the provision or construction of sanitation facilities by
    the Secretary.
        [(e) Amount of assistance]
        [(1)] (e) Financial Assistance.--The Secretary is
    authorized to provide financial assistance to Indian [tribes
    and communities in an amount equal to the Federal share of the
    costs of operating, managing, and maintaining the facilities
    provided under the plan described in subsection (c) of this
    section.] Tribes, Tribal Organizations, and Indian communities
    for operation, management, and maintenance of their sanitation
    facilities.
              [(2) For the purposes of paragraph (1), the term
            ``Federal share'' means 80 percent of the costs
            described in paragraph (1).
              [(3) With respect to Indian tribes with fewer than
            1,000 enrolled members, the non-Federal portion of the
            costs of operating, managing, and maintaining such
            facilities may be provided, in part, through cash
            donations or in kind property, fairly evaluated.
        [(f) Eligibility of programs administered by Indian tribes
        [Programs administered by Indian tribes or tribal
    organizations under the authority of the Indian Self-
    Determination Act [25 U.S.C.A. Sec. 450f et seq.] shall be
    eligible for--
              [(1) any funds appropriated pursuant to this section,
            and
              [(2) any funds appropriated for the purpose of
            providing water supply or sewage disposal services,
    [on an equal basis with programs that are administered directly
    by the Service.
        [(g) Annual]
        (f) Operation, Management, and Maintenance of Facilities.--
    The Indian Tribe has the primary responsibility to establish,
    collect, and use reasonable user fees, or otherwise set aside
    funding, for the purpose of operating, managing, and
    maintaining sanitation facilities. If a sanitation facility
    serving a community that is operated by an Indian Tribe or
    Tribal Organization is threatened with imminent failure and
    such operator lacks capacity to maintain the integrity or the
    health benefits of the sanitation facility, then the Secretary
    is authorized to assist the Indian Tribe, Tribal Organization,
    or Indian community in the resolution of the problem on a
    short-term basis through cooperation with the emergency
    coordinator or by providing operation, management, and
    maintenance service.
        (g) ISDEAA Program Funded on Equal Basis.--Tribal Health
    Programs shall be eligible (on an equal basis with programs
    that are administered directly by the Service) for--
              (1) any funds appropriated pursuant to this section;
            and
              (2) any funds appropriated for the purpose of
            providing sanitation facilities.
        (h) Report.--
              (1) Required; contents.--The Secretary, in
            consultation with the Secretary of Housing and Urban
            Development, Indian Tribes, Tribal Organizations, and
            tribally designated housing entities (as defined in
            section 4 of the Native American Housing Assistance and
            Self-Determination Act of 1996 (25 U.S.C. 4103)) shall
            submit to the President, for inclusion in the report[;
            sanitation deficiency levels]
              [(1) The Secretary shall submit to the President, for
            inclusion in each report required to be transmitted to
            the [Congress under section 1671 of this title,]
            Congress under section 801, a report which sets forth--
                      [(A) the current Indian sanitation facility
                    priority system of the Service;]
                      (A) the current Indian sanitation facility
                    priority system of the Service;
                      (B) the methodology for determining
                    sanitation deficiencies[;]
                      [(C) the level of sanitation deficiency for
                    each sanitation facilities project of each
                    Indian tribe or community;
                      [(D) the amount of funds necessary to raise
                    all Indian tribes and communities to a level I
                    sanitation deficiency; and
                      [(E) the amount of funds necessary to raise
                    all Indian tribes and communities to zero
                    sanitation deficiency.
              [(2) In preparing each report required under
            paragraph (1) (other than the initial report), the
            Secretary shall consult with Indian tribes and tribal
            organizations (including those tribes or tribal
            organizations operating health care programs or
            facilities under any contract entered into with the
            Service under the Indian Self-Determination Act [25
            U.S.C.A. Sec. 450f et seq.]) to determine the
            sanitation needs of each tribe.] and needs;
                      (C) the criteria on which the deficiencies
                    and needs will be evaluated;
                      (D) the level of initial and final sanitation
                    deficiency for each type of sanitation facility
                    for each project of each Indian Tribe or Indian
                    community;
                      (E) the amount and most effective use of
                    funds, derived from whatever source, necessary
                    to accommodate the sanitation facilities needs
                    of new homes assisted with funds under the
                    Native American Housing Assistance and Self-
                    Determination Act (25 U.S.C. 4101 et seq.), and
                    to reduce the identified sanitation deficiency
                    levels of all Indian Tribes and Indian
                    communities to level I sanitation deficiency as
                    defined in paragraph (3)(A); and
                      (F) a 10-year plan to provide sanitation
                    facilities to serve existing Indian homes and
                    Indian communities and new and renovated Indian
                    homes.
              [(3)] (2) Uniform methodology.--The methodology used
            by the Secretary in determining, preparing cost
            estimates for, and reporting sanitation deficiencies
            for purposes of paragraph (1) shall be applied
            uniformly to all Indian [tribes and] Tribes and Indian
            communities.
              [(4)] (3) Sanitation deficiency levels.--For purposes
            of this subsection, the sanitation deficiency levels
            for an [Indian tribe or community are] individual,
            Indian Tribe, or Indian community sanitation facility
            to serve Indian homes are determined as follows:
                      [(A) level I is an Indian tribe or community
                    with a sanitation system--]
                      (A) A level I deficiency exists if a
                    sanitation facility serving an individual,
                    Indian Tribe, or Indian community--
                              (i) [which] complies with all
                            applicable water supply [and,]
                            pollution control, and solid waste
                            disposal laws[,]; and
                              (ii) [in which the] deficiencies
                            relate to routine replacement, repair,
                            or maintenance needs[;].
                      (B) A level II [is an Indian tribe or
                    community with a sanitation system--]
                              [(i) which complies] deficiency
                            exists if a sanitation facility serving
                            an individual, Indian Tribe, or Indian
                            community substantially or recently
                            complied with all applicable water
                            supply [and], pollution control [laws,
                            and (ii) in which the], and solid waste
                            laws and any deficiencies relate to--
                              (i) small or minor capital
                            improvements needed to bring the
                            facility back into compliance;
                              (ii) capital improvements that are
                            necessary to enlarge or improve the
                            facilities in order to meet the current
                            needs [of such tribe or community] for
                            domestic sanitation facilities; or
                              (iii) the lack of equipment or
                            training by an Indian Tribe, Tribal
                            Organization, or an Indian community to
                            properly operate and maintain the
                            sanitation facilities.
                      (C) A level III [is an Indian tribe or
                    community with a sanitation system which--]
                    deficiency exists if a sanitation facility
                    serving an individual, Indian Tribe or Indian
                    community meets 1 or more of the following
                    conditions--
                              [(i) has an inadequate or partial
                            water supply and a sewage disposal
                            facility that does not comply with
                            applicable water supply and pollution
                            control laws, or
                              [(ii) has no solid waste disposal
                            facility;
                      [(D) level IV is an Indian tribe or community
                    with a sanitation system which lacks either a
                    safe water supply system or a sewage disposal
                    system; and
                      [(E) level V is an Indian tribe or community
                    that lacks a safe water supply and a sewage
                    disposal system.
              [(5) For purposes of this subsection, any Indian
            tribe or community that lacks the operation and
            maintenance capability to enable its sanitation system
            to meet pollution control laws may not be treated as
            having a level I or II sanitation deficiency.]
                              (i) water or sewer service in the
                            home is provided by a haul system with
                            holding tanks and interior plumbing;
                              (ii) major significant interruptions
                            to water supply or sewage disposal
                            occur frequently, requiring major
                            capital improvements to correct the
                            deficiencies; or
                              (iii) there is no access to or no
                            approved or permitted solid waste
                            facility available.
                      (D) A level IV deficiency exists--
                              (i) if a sanitation facility for an
                            individual home, an Indian Tribe, or an
                            Indian community exists but--
                                      (I) lacks--
                                              (aa) a safe water
                                            supply system; or
                                              (bb) a waste disposal
                                            system;
                                      (II) contains no piped water
                                    or sewer facilities; or
                                      (III) has become inoperable
                                    due to a major component
                                    failure; or
                              (ii) if only a washeteria or central
                            facility exists in the community.
                      (E) A level V deficiency exists in the
                    absence of a sanitation facility, where
                    individual homes do not have access to safe
                    drinking water or adequate wastewater
                    (including sewage) disposal.
                              (i) Definitions.--For purposes of
                            this section, the following terms
                            apply:
              (1) Indian community.--The term ``Indian community''
            means a geographic area, a significant proportion of
            whose inhabitants are Indians and which is served by or
            capable of being served by a facility described in this
            section.
              (2) Sanitation facilities.--The terms ``sanitation
            facility'' and ``sanitation facilities'' mean safe and
            adequate water supply systems, sanitary sewage disposal
            systems, and sanitary solid waste systems (and all
            related equipment and support infrastructure).

    [Sec. 1633. Preference to Indians and Indian firms]

    SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS.

        [(a) Discretionary authority; covered activities]
        (a) Buy Indian Act.--The Secretary, acting through the
    Service, may [utilize] use the negotiating authority of section
    [47 of this title] 23 of the Act of June 25, 1910 (25 U.S.C.
    47, commonly known as the ``Buy Indian Act''), to give
    preference to any Indian or any enterprise, partnership,
    corporation, or other type of business organization owned and
    controlled by an Indian or Indians including former or
    currently federally recognized Indian [tribes] Tribes in the
    State of New York (hereinafter referred to as an ``Indian
    firm'') in the construction and renovation of Service
    facilities pursuant to section [1631 of this title and in the
    construction of safe water and sanitary waste disposal] 301 and
    in the construction of sanitation facilities pursuant to
    section [1632 of this title.] 302. Such preference may be
    accorded by the Secretary unless [he] the Secretary finds,
    pursuant to [rules and] regulations [promulgated by him], that
    the project or function to be contracted for will not be
    satisfactory or such project or function cannot be properly
    completed or maintained under the proposed contract. The
    Secretary, in arriving at [his] such a finding, shall consider
    whether the Indian or Indian firm will be deficient with
    respect to--
              (1) ownership and control by Indians[,];
              (2) equipment[,];
              (3) bookkeeping and accounting procedures[,];
              (4) substantive knowledge of the project or function
            to be contracted for[,];
              (5) adequately trained personnel[,]; or
              (6) other necessary components of contract
            performance.
        [(b) Pay rates]
        (b) Labor Standards.--
              (1) In general.--For the [purpose] purposes of
            implementing the provisions of this [subchapter, the
            Secretary shall assure that the rates of pay for
            personnel engaged in] title, contracts for the
            construction or renovation of [facilities constructed
            or renovated] health care facilities, staff quarters,
            and sanitation facilities, and related support
            infrastructure, funded in whole or in part [by] with
            funds made available pursuant to this title [[25
            U.S.C.A. Sec. Sec. 1631 et seq.] are not less than the
            prevailing local wage rates for similar work as
            determined in accordance with the Act of March 3, 1931
            (40 U.S.C. 276a to 276a-5, known as the Davis-Bacon
            Act).], shall contain a provision requiring compliance
            with subchapter IV of chapter 31 of title 40, United
            States Code (commonly known as the ``Davis-Bacon
            Act''), unless such construction or renovation--
                      (A) is performed by a contractor pursuant to
                    a contract with an Indian Tribe or Tribal
                    Organization with funds supplied through a
                    contract or compact authorized by the Indian
                    Self-Determination and Education Assistance Act
                    (25 U.S.C. 450 et seq.), or other statutory
                    authority; and
                      (B) is subject to prevailing wage rates for
                    similar construction or renovation in the
                    locality as determined by the Indian Tribes or
                    Tribal Organizations to be served by the
                    construction or renovation.
              (2) Exception.--This subsection shall not apply to
            construction or renovation carried out by an Indian
            Tribe or Tribal Organization with its own employees.

    [Sec. 1634. Expenditure of non-Service funds for renovation]

    SEC. 304. EXPENDITURE OF NON-SERVICE FUNDS FOR RENOVATION.

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

    SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, AND MODERNIZATION OF
                        SMALL AMBULATORY CARE FACILITIES.

    [Sec. 1636. Grant program for the construction, expansion, and
                        modernization of small ambulatory care facilities]

        (a) Grants._
        [(a) Authorization]
              (1) In general._The Secretary, acting through the
            Service, shall make grants to [tribes and tribal
            organizations] Indian Tribes and Tribal Organizations
            for the construction, expansion, or modernization of
            facilities for the provision of ambulatory care
            services to eligible Indians (and noneligible persons
            [as provided in subsection] pursuant to subsections
            (b)(2) and (c)(1)(C)[ of this section]). A grant made
            under this section may cover up to 100 percent of the
            costs of such construction, expansion, or
            modernization. For the purposes of this section, the
            term ``construction'' includes the replacement of an
            existing facility.
              (2) Grant agreement required._A grant under paragraph
            (1) may only be made [to a tribe or tribal
            organization] available to a Tribal Health Program
            operating an Indian health facility (other than a
            facility owned or constructed by the Service, including
            a facility originally owned or constructed by the
            Service and transferred to [a tribe or tribal
            organization) pursuant to a contract entered into under
            the Indian Self-Determination Act [25 U.S.C.A.
            Sec. 450f et seq.].] an Indian Tribe or Tribal
            Organization).
        [(b) Use of grant
              (1) A grant provided under this section may be used
            only for the construction, expansion, or modernization
            (including the planning and design of such
            construction, expansion, or modernization) of an
            ambulatory care facility--]
        (b) Use of Grant Funds.--
              (1) Allowable uses.--A grant awarded under this
            section may be used for the construction, expansion, or
            modernization (including the planning and design of
            such construction, expansion, or modernization) of an
            ambulatory care facility--
                      (A) located apart from a hospital;
                      (B) not funded under section [1631] 301 or
                    section [1637 of this title] 306; and
                      (C) which, upon completion of such
                    construction[, expansion,] or modernization
                    will--
                              (i) have a total capacity appropriate
                            to its projected service population;
                              [(ii) serve no less than 500](ii)
                            provide annually no fewer than 150
                            patient visits by eligible Indians
                            [annually;] and other users who are
                            eligible for services in such facility
                            in accordance with section 807(c)(2);
                            and
                              (iii) provide ambulatory care in a
                            [service area] Service Area (specified
                            in the contract [entered into] or
                            compact under the Indian Self-
                            Determination and Education Assistance
                            Act [[](25 U.S.C.[A. Sec. ]450[f et
                            seq.]] et seq.)) with a population of
                            [not less than 2,000] no fewer than
                            1,500 eligible Indians[.] and other
                            users who are eligible for services in
                            such facility in accordance with
                            section 807(c)(2).
              (2) Additional allowable use.--The Secretary may also
            reserve a portion of the funding provided under this
            section and use those reserved funds to reduce an
            outstanding debt incurred by Indian Tribes or Tribal
            Organizations for the construction, expansion, or
            modernization of an ambulatory care facility that meets
            the requirements under paragraph (1). The provisions of
            this section shall apply, except that such applications
            for funding under this paragraph shall be considered
            separately from applications for funding under
            paragraph (1).
              [(2)] (3) Use only for certain portion of costs._A
            grant provided under this section may be used only for
            the cost of that portion of a construction, expansion,
            or modernization project that benefits the Service
            population identified above in subsection (b)(1)(C)
            (ii) and (iii). The requirements of clauses (ii) and
            (iii) of paragraph (1)(C) shall not apply to [a tribe
            or tribal organization] an Indian Tribe or Tribal
            Organization applying for a grant under this section
            [whose tribal government offices are located on an
            island] for a health care facility located or to be
            constructed on an island or when such facility is not
            located on a road system providing direct access to an
            inpatient hospital where care is available to the
            Service population.
        [(c) Application of grant]
        (c) Grants.--
              (1) Application._No grant may be made under this
            section unless an application or proposal for [such a]
            the grant has been[ submitted to and] approved by the
            Secretary[. An application for a grant under this
            section shall be submitted in such form and manner as
            the Secretary shall by regulation prescribe and shall]
            in accordance with applicable regulations and has set
            forth reasonable assurance by the applicant that, at
            all times after the construction, expansion, or
            modernization of a facility carried out [pursuant to]
            using a grant received under this section--
                      (A) adequate financial support will be
                    available for the provision of services at such
                    facility;
                      (B) such facility will be available to
                    eligible Indians without regard to ability to
                    pay or source of payment; and
                      (C) such facility will, as feasible without
                    diminishing the quality or quantity of services
                    provided to eligible Indians, serve noneligible
                    persons on a cost basis.
              (2) Priority.--In awarding grants under this section,
            the Secretary shall give priority to [tribes and tribal
            organizations]Indian Tribes and Tribal Organizations
            that demonstrate--
                      (A) a need for increased ambulatory care
                    services; and
                      (B) insufficient capacity to deliver such
                    services.
              (3) Peer review panels.--The Secretary may provide
            for the establishment of peer review panels, as
            necessary, to review and evaluate applications and
            proposals and to advise the Secretary regarding such
            applications using the criteria developed pursuant to
            subsection (a)(1).
        (d) [Transfer of interest to United States upon cessation
    of facility]Reversion of Facilities._If any facility (or
    portion thereof) with respect to which funds have been paid
    under this section, ceases, at any time after completion of the
    construction, expansion, or modernization carried out with such
    funds, to be [utilized] used for the purposes of providing
    [ambulatory] health care services to eligible Indians, all of
    the right, title, and interest in and to such facility (or
    portion thereof) shall transfer to the United States unless
    otherwise negotiated by the Service and the Indian Tribe or
    Tribal Organization.
        (e) Funding Nonrecurring.--Funding provided under this
    section shall be nonrecurring and shall not be available for
    inclusion in any individual Indian Tribe's tribal share for an
    award under the Indian Self-Determination and Education
    Assistance Act (25 U.S.C. 450 et seq.) or for reallocation or
    redesign thereunder.

    [Sec. 1637. Indian health care delivery demonstration project]

    SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRATION PROJECTS.

        [(a) Health care delivery demonstration projects]
        (a) In General.--The Secretary, acting through the Service,
    is authorized to carry out, or to enter into contracts [with,
    or make grants to, Indian tribes or tribal organizations for
    the purpose of carrying out]under the Indian Self-Determination
    and Education Assistance Act (25 U.S.C. 450 et seq.) with
    Indian Tribes or Tribal Organizations to carry out, a health
    care delivery demonstration project to test alternative means
    of delivering health care and services to Indians through
    [health] facilities [to Indians].
        (b) Use of [funds]Funds.--The Secretary, in approving
    projects pursuant to this section, may authorize [funding] such
    contracts for the construction and renovation of hospitals,
    health centers, health stations, and other facilities to
    deliver health care services and is authorized to--
              (1) waive any leasing prohibition;
              (2) permit carryover of funds appropriated for the
            provision of health care services;
              (3) permit the use of [non-Service Federal funds and
            non-Federal]other available funds;
              (4) permit the use of funds or property donated from
            any source for project purposes; [and]
              (5) provide for the reversion of donated real or
            personal property to the donor[.]; and
        [(c) Criteria]
              (6) permit the use of Service funds to match other
            funds, including Federal funds.
        (c) Health Care Demonstration Projects.--
              (1) General projects.--
              [(1) Within 180 days after November 28, 1990, the
            Secretary, after consultation with Indian tribes and
            tribal organizations, shall develop and publish in the
            Federal Register criteria for the review and approval
            of applications submitted under this section. The
            Secretary may enter into a contract or award a grant
            under this section for projects which]
                      (A) Criteria._The Secretary may approve under
                    this section demonstration projects that meet
                    the following criteria:
                              [(A)] (i)There is a need for a new
                            facility or program, such as a program
                            for convenient care services, or the
                            reorientation of an existing facility
                            or program.
                              [(B)] (ii) A significant number of
                            Indians, including [those] Indians with
                            low health status, will be served by
                            the project.
                              [(C) The project has the potential to
                            address the health needs of Indians in
                            an innovative manner.]
                              [(D)] (iii) The project has the
                            potential to deliver services in an
                            efficient and effective manner.
                              [(E)] (iv) The project is
                            economically viable.
                              [(F)] (v) [The Indian tribe or tribal
                            organization] For projects carried out
                            by an Indian Tribe or Tribal
                            Organization, the Indian Tribe or
                            Tribal Organization has the
                            administrative and financial capability
                            to administer the project.
                              [(G)] (vi) The project is integrated
                            with providers of related health and
                            social services and is coordinated
                            with, and avoids duplication of,
                            existing services in order to expand
                            the availability of services.
              [(2) The Secretary may provide for the establishment
            of peer review panels, as necessary, to review and
            evaluate applications and to advise the Secretary
            regarding such applications using the criteria
            developed pursuant to paragraph (1).
              [(3)(A) On or before September 30, 1995, the
            Secretary shall enter into contracts or award grants
            under this section for a demonstration project in each
            of the following service units which meets the criteria
            specified in paragraph (1) and for which a completed
            application has been received by the Secretary:]
                      (B) Priority.--In approving demonstration
                    projects under this paragraph, the Secretary
                    shall give priority to demonstration projects,
                    to the extent the projects meet the criteria
                    described in subparagraph (A), located in any
                    of the following Service Units:
                              (i) Cass Lake, Minnesota.
                      (ii[) Clinton, Oklahoma.
                              [(iii) Harlem, Montana.
                              (iv]) Mescalero, New Mexico.
                              ([v]iii) Owyhee, Nevada.
                              [(vi) Parker, Arizona.]
                              ([vii]iv) Schurz, Nevada.
                              [(viii) Winnebago, Nebraska.]
                              ([ix]v) Ft. Yuma, California.
                      [(B) The Secretary may also enter into
                    contracts or award grants under this section
                    taking into consideration applications received
                    under this section from all service areas. The
                    Secretary may not award a greater number of
                    such contracts or grants in one service area
                    than in any other service area until there is
                    an equal number of such contracts or grants
                    awarded with respect to all service areas from
                    which the Secretary receives applications
                    during the application period (as determined by
                    the Secretary) which meet the criteria
                    specified in paragraph (1).]
              (2) Convenient care service projects.--
                      (A) Definition of convenient care service.--
                    In this paragraph, the term ``convenient care
                    service'' means any primary health care
                    service, such as urgent care services,
                    nonemergent care services, prevention services
                    and screenings, and any service authorized by
                    sections 203 or 213(d), that is--
                              (i) provided outside the regular
                            hours of operation of a health care
                            facility; or
                              (ii) offered at an alternative
                            setting.
                      (B) Approval.--In addition to projects
                    described in paragraph (1), in any fiscal year,
                    the Secretary is authorized to approve not more
                    than 10 applications for health care delivery
                    demonstration projects that--
                              (i) include a convenient care
                            services program as an alternative
                            means of delivering health care
                            services to Indians; and
                              (ii) meet the criteria described in
                            subparagraph (C).
                      (C) Criteria.--The Secretary shall approve
                    under subparagraph (B) demonstration projects
                    that meet all of the following criteria:
                              (i) The criteria set forth in
                            paragraph (1)(A).
                              (ii) There is a lack of access to
                            health care services at existing health
                            care facilities, which may be due to
                            limited hours of operation at those
                            facilities or other factors.
                              (iii) The project--
                                      (I) expands the availability
                                    of services; or
                                      (II) reduces--
                                              (aa) the burden on
                                            Contract Health
                                            Services; or
                                              (bb) the need for
                                            emergency room visits.
        (d) Peer Review Panels.--The Secretary may provide for the
    establishment of peer review panels, as necessary, to review
    and evaluate applications using the criteria described in
    paragraphs (1)(A) and (2)(C) of subsection (c).
        ([d]e) Technical [assistance] Assistance._The Secretary
    shall provide such technical and other assistance as may be
    necessary to enable applicants to comply with [the provisions
    of] this section.
        ([e]f) Service to [ineligible persons The]Ineligible
    Persons._ Subject to section 807, the authority to provide
    services to persons otherwise ineligible for the health care
    benefits of the Service, and the authority to extend hospital
    privileges in [service]Service facilities to non-Service health
    [care] practitioners as provided in section [1680c of this
    title] 807, may be included, subject to the terms of [such]
    that section, in any demonstration project approved pursuant to
    this section.
        ([f]g) Equitable [treatment] Treatment._For purposes of
    subsection (c)[(1)(A) of this section,] the Secretary [shall],
    in evaluating facilities operated under any contract [entered
    into with the Service] or compact under the Indian Self-
    Determination and Education Assistance Act[ [](25 U.S.C.[A.
    Sec. ]450[f] et seq.],), shall use the same criteria that the
    Secretary uses in evaluating facilities operated directly by
    the Service.
        ([g]h Equitable [integration of facilities] Integration of
    Facilities._The Secretary shall ensure that the planning,
    design, construction, [and] renovation, and expansion needs of
    Service and non-Service facilities [which] that are the subject
    of a contract [for health services entered into with the
    Service]or compact under the Indian Self-Determination and
    Education Assistance Act [[](25 U.S.C.[A. Sec. ]450[f] et
    seq.],) for health services are fully and equitably integrated
    into the implementation of the health care delivery
    demonstration projects under this section.
        [(h) Reports to Congress
              [(1) The Secretary shall submit to the President, for
            inclusion in the report which is required to be
            submitted to the Congress under section 1671 of this
            title for fiscal year 1997, an interim report on the
            findings and conclusions derived from the demonstration
            projects established under this section.
              [(2) The Secretary shall submit to the President, for
            inclusion in the report which is required to be
            submitted to the Congress under section 1671 of this
            title for fiscal year 1999, a final report on the
            findings and conclusions derived from the demonstration
            projects established under this section, together with
            legislative recommendations.

    SEC. 307. LAND TRANSFER.

        Notwithstanding any other provision of law, the Bureau of
    Indian Affairs and all other agencies and departments of the
    United States are authorized to transfer, at no cost, land and
    improvements to the Service for the provision of health care
    services. The Secretary is authorized to accept such land and
    improvements for such purposes.

    SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS.

        The Secretary, acting through the Service, may enter into
    leases, contracts, and other agreements with Indian Tribes and
    Tribal Organizations which hold (1) title to, (2) a leasehold
    interest in, or (3) a beneficial interest in (when title is
    held by the United States in trust for the benefit of an Indian
    Tribe) facilities used or to be used for the administration and
    delivery of health services by an Indian Health Program. Such
    leases, contracts, or agreements may include provisions for
    construction or renovation and provide for compensation to the
    Indian Tribe or Tribal Organization of rental and other costs
    consistent with section 105(l) of the Indian Self-Determination
    and Education Assistance Act (25 U.S.C. 450j(l)) and
    regulations thereunder.

    SEC. 309. STUDY ON LOANS, LOAN GUARANTEES, AND LOAN REPAYMENT.

        (a) In General.--The Secretary, in consultation with the
    Secretary of the Treasury, Indian Tribes, and Tribal
    Organizations, shall carry out a study to determine the
    feasibility of establishing a loan fund to provide to Indian
    Tribes and Tribal Organizations direct loans or guarantees for
    loans for the construction of health care facilities,
    including--
              (1) inpatient facilities;
              (2) outpatient facilities;
              (3) staff quarters;
              (4) hostels; and
              (5) specialized care facilities, such as behavioral
            health and elder care facilities.
        (b) Determinations.--In carrying out the study under
    subsection (a), the Secretary shall determine--
              (1) the maximum principal amount of a loan or loan
            guarantee that should be offered to a recipient from
            the loan fund;
              (2) the percentage of eligible costs, not to exceed
            100 percent, that may be covered by a loan or loan
            guarantee from the loan fund (including costs relating
            to planning, design, financing, site land development,
            construction, rehabilitation, renovation, conversion,
            improvements, medical equipment and furnishings, and
            other facility-related costs and capital purchase (but
            excluding staffing));
              (3) the cumulative total of the principal of direct
            loans and loan guarantees, respectively, that may be
            outstanding at any one time;
              (4) the maximum term of a loan or loan guarantee that
            may be made for a facility from the loan fund;
              (5) the maximum percentage of funds from the loan
            fund that should be allocated for payment of costs
            associated with planning and applying for a loan or
            loan guarantee;
              (6) whether acceptance by the Secretary of an
            assignment of the revenue of an Indian Tribe or Tribal
            Organization as security for any direct loan or loan
            guarantee from the loan fund would be appropriate;
              (7) whether, in the planning and design of health
            facilities under this section, users eligible under
            section 807(c) may be included in any projection of
            patient population;
              (8) whether funds of the Service provided through
            loans or loan guarantees from the loan fund should be
            eligible for use in matching other Federal funds under
            other programs;
              (9) the appropriateness of, and best methods for,
            coordinating the loan fund with the health care
            priority system of the Service under section 301; and
              (10) any legislative or regulatory changes required
            to implement recommendations of the Secretary based on
            results of the study.
        (c) Report.--Not later than September 30, 2009, the
    Secretary shall submit to the Committee on Indian Affairs of
    the Senate and the Committee on Natural Resources and the
    Committee on Energy and Commerce of the House of
    Representatives a report that describes--
              (1) the manner of consultation made as required by
            subsection (a); and
              (2) the results of the study, including any
            recommendations of the Secretary based on results of
            the study.

    SEC. 310. TRIBAL LEASING.

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

    SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES JOINT VENTURE
                        PROGRAM.

        (a) In General.--The Secretary, acting through the Service,
    shall make arrangements with Indian Tribes and Tribal
    Organizations to establish joint venture demonstration projects
    under which an Indian Tribe or Tribal Organization shall expend
    tribal, private, or other available funds, for the acquisition
    or construction of a health facility for a minimum of 10 years,
    under a no-cost lease, in exchange for agreement by the Service
    to provide the equipment, supplies, and staffing for the
    operation and maintenance of such a health facility. An Indian
    Tribe or Tribal Organization may use tribal funds, private
    sector, or other available resources, including loan
    guarantees, to fulfill its commitment under a joint venture
    entered into under this subsection. An Indian Tribe or Tribal
    Organization shall be eligible to establish a joint venture
    project if, when it submits a letter of intent, it--
              (1) has begun but not completed the process of
            acquisition or construction of a health facility to be
            used in the joint venture project; or
              (2) has not begun the process of acquisition or
            construction of a health facility for use in the joint
            venture project.
        (b) Requirements.--The Secretary shall make such an
    arrangement with an Indian Tribe or Tribal Organization only
    if--
              (1) the Secretary first determines that the Indian
            Tribe or Tribal Organization has the administrative and
            financial capabilities necessary to complete the timely
            acquisition or construction of the relevant health
            facility; and
              (2) the Indian Tribe or Tribal Organization meets the
            need criteria determined using the criteria developed
            under the health care facility priority system under
            section 301, unless the Secretary determines, pursuant
            to regulations, that other criteria will result in a
            more cost-effective and efficient method of
            facilitating and completing construction of health care
            facilities.
        (c) Continued Operation.--The Secretary shall negotiate an
    agreement with the Indian Tribe or Tribal Organization
    regarding the continued operation of the facility at the end of
    the initial 10 year no-cost lease period.
        (d) Breach of Agreement.--An Indian Tribe or Tribal
    Organization that has entered into a written agreement with the
    Secretary under this section, and that breaches or terminates
    without cause such agreement, shall be liable to the United
    States for the amount that has been paid to the Indian Tribe or
    Tribal Organization, or paid to a third party on the Indian
    Tribe's or Tribal Organization's behalf, under the agreement.
    The Secretary has the right to recover tangible property
    (including supplies) and equipment, less depreciation, and any
    funds expended for operations and maintenance under this
    section. The preceding sentence does not apply to any funds
    expended for the delivery of health care services, personnel,
    or staffing.
        (e) Recovery for Nonuse.--An Indian Tribe or Tribal
    Organization that has entered into a written agreement with the
    Secretary under this subsection shall be entitled to recover
    from the United States an amount that is proportional to the
    value of such facility if, at any time within the 10-year term
    of the agreement, the Service ceases to use the facility or
    otherwise breaches the agreement.
        (f) Definition.--For the purposes of this section, the term
    ``health facility'' or ``health facilities'' includes quarters
    needed to provide housing for staff of the relevant Tribal
    Health Program.

    SEC. 312. LOCATION OF FACILITIES.

        (a) In General.--In all matters involving the
    reorganization or development of Service facilities or in the
    establishment of related employment projects to address
    unemployment conditions in economically depressed areas, the
    Bureau of Indian Affairs and the Service shall give priority to
    locating such facilities and projects on Indian lands, or lands
    in Alaska owned by any Alaska Native village, or village or
    regional corporation under the Alaska Native Claims Settlement
    Act (43 U.S.C. 1601 et seq.), or any land allotted to any
    Alaska Native, if requested by the Indian owner and the Indian
    Tribe with jurisdiction over such lands or other lands owned or
    leased by the Indian Tribe or Tribal Organization. Top priority
    shall be given to Indian land owned by 1 or more Indian Tribes.
        (b) Definition.--For purposes of this section, the term
    ``Indian lands'' means--
              (1) all lands within the exterior boundaries of any
            reservation; and
              (2) any lands title to which is held in trust by the
            United States for the benefit of any Indian Tribe or
            individual Indian or held by any Indian Tribe or
            individual Indian subject to restriction by the United
            States against alienation.

    SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH CARE FACILITIES.

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

    SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY-OWNED QUARTERS.

        (a) Rental Rates.--
              (1) Establishment.--Notwithstanding any other
            provision of law, a Tribal Health Program which
            operates a hospital or other health facility and the
            federally-owned quarters associated therewith pursuant
            to a contract or compact under the Indian Self-
            Determination and Education Assistance Act (25 U.S.C.
            450 et seq.) shall have the authority to establish the
            rental rates charged to the occupants of such quarters
            by providing notice to the Secretary of its election to
            exercise such authority.
              (2) Objectives.--In establishing rental rates
            pursuant to authority of this subsection, a Tribal
            Health Program shall endeavor to achieve the following
            objectives:
                      (A) To base such rental rates on the
                    reasonable value of the quarters to the
                    occupants thereof.
                      (B) generate sufficient funds to prudently
                    provide for the operation and maintenance of
                    the quarters, and subject to the discretion of
                    the Tribal Health Program, to supply reserve
                    funds for capital repairs and replacement of
                    the quarters.
             (3) Equitable funding.--Any quarters whose rental
            rates are established by a Tribal Health Program
            pursuant to this subsection shall remain eligible for
            quarters improvement and repair funds to the same
            extent as all federally-owned quarters used to house
            personnel in Services-supported programs.
              (4) Notice of rate change.--A Tribal Health Program
            which exercises the authority provided under this
            subsection shall provide occupants with no less than 60
            days notice of any change in rental rates.
        (b) Direct Collection of Rent.--
              (1) In general.--Notwithstanding any other provision
            of law, and subject to paragraph (2), a Tribal Health
            Program shall have the authority to collect rents
            directly from Federal employees who occupy such
            quarters in accordance with the following:
                      (A) The Tribal Health Program shall notify
                    the Secretary and the subject Federal employees
                    of its election to exercise its authority to
                    collect rents directly from such Federal
                    employees.
                      (B) Upon receipt of a notice described in
                    subparagraph (A), the Federal employees shall
                    pay rents for occupancy of such quarters
                    directly to the Tribal Health Program and the
                    Secretary shall have no further authority to
                    collect rents from such employees through
                    payroll deduction or otherwise.
                      (C) Such rent payments shall be retained by
                    the Tribal Health Program and shall not be made
                    payable to or otherwise be deposited with the
                    United States.
                      (D) Such rent payments shall be deposited
                    into a separate account which shall be used by
                    the Tribal Health Program for the maintenance
                    (including capital repairs and replacement) and
                    operation of the quarters and facilities as the
                    Tribal Health Program shall determine.
              (2) Retrocession of authority.--If a Tribal Health
            Program which has made an election under paragraph (1)
            requests retrocession of its authority to directly
            collect rents from Federal employees occupying
            federally-owned quarters, such retrocession shall
            become effective on the earlier of--

    [Sec. 1638. Land transfer]

                      (A) the first day of the month that begins no
                    less than 180 days after the Tribal Health
                    Program notifies the Secretary of its desire to
                    retrocede; or
        [The Bureau of Indian Affairs is authorized to transfer, at
    no cost, up to 5 acres of land at the Chemawa Indian School,
    Salem, Oregon, to the Service for the provision of health care
    services. The land authorized to be transferred by this section
    is that land adjacent to land under the jurisdiction of the
    Service and occupied by the Chemawa Indian Health Center.]
                     (B) such other date as may be mutually agreed
                    by the Secretary and the Tribal Health Program.

    [Sec. 1638a. Authorization of appropriations]

        (c) Rates in Alaska.--To the extent that a Tribal Health
    Program, pursuant to authority granted in subsection (a),
    establishes rental rates for federally-owned quarters provided
    to a Federal employee in Alaska, such rents may be based on the
    cost of comparable private rental housing in the nearest
    established community with a year-round population of 1,500 or
    more individuals.
        [There are authorized to be appropriated such sums as may
    be necessary for each fiscal year through fiscal year 2000 to
    carry out this subchapter.]

    SEC. 315. APPLICABILITY OF BUY AMERICAN ACT REQUIREMENT.

    [Sec. 1638b.]

        (a) Applicability [of Buy American requirement (a) Duty of
    Secretary].--The Secretary shall ensure that the requirements
    of the Buy American Act [[41 U.S.C.A. Sec. 10a et seq.]] apply
    to all procurements made with funds provided pursuant to [the
    authorization contained in section 1638a of this title.]
    section 317. Indian Tribes and Tribal Organizations shall be
    exempt from these requirements.
        [(b) Report to Congress
        [The Secretary shall submit to the Congress a report on the
    amount of procurements from foreign entities made in fiscal
    years 1993 and 1994 with funds provided pursuant to the
    authorization contained in section 1638a of this title. Such
    report shall separately indicate the dollar value of items
    procured with such funds for which the Buy American Act [41
    U.S.C.A. Sec. 10a et seq.] was waived pursuant to the Trade
    Agreement Act of 1979 [19 U.S.C.A. Sec. 250 et seq.] or any
    international agreement to which the United States is a party.
        [(c) Fraudulent use of Made-in-America label]
        (b) Effect of Violation.--If it has been finally determined
    by a court or Federal agency that any person intentionally
    affixed a label bearing a ``Made in America'' inscription[,] or
    any inscription with the same meaning, to any product sold in
    or shipped to the United States that is not made in the United
    States, such person shall be ineligible to receive any contract
    or subcontract made with funds provided pursuant to [the
    authorization contained in] section [1638a of this title,] 317,
    pursuant to the debarment, suspension, and ineligibility
    procedures described in sections 9.400 through 9.409 of title
    48, Code of Federal Regulations.
        [(d) ``Buy American Act'' defined] (c) Definitions.--For
    purposes of this section, the term [``Buy American Act''] ``Buy
    American Act'' means title III of the Act entitled ``An Act
    making appropriations for the Treasury and Post Office
    Departments for the fiscal year ending June 30, 1934, and for
    other purposes'', approved March 3, 1933 (41 U.S.C. 10a et
    seq.).

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

        [In fiscal year 1995 and thereafter--]

    SEC. 316. OTHER FUNDING FOR FACILITIES.

        [(a) In general
        [The Secretary may enter into personal services contracts
    with entities, either individuals or organizations, for the
    provision of services in facilities owned, operated or
    constructed under the jurisdiction of the Indian Health
    Service.]
        (a) Authority To Accept Funds.--The Secretary is authorized
    to accept from any source, including Federal and State
    agencies, funds that are available for the construction of
    health care facilities and use such funds to plan, design, and
    construct health care facilities for Indians and to place such
    funds into a contract or compact under the Indian Self-
    Determination and Education Assistance Act (25 U.S.C. 450 et
    seq.). Receipt of such funds shall have no effect on the
    priorities established pursuant to section 301.
        [(b) Exemption from competitive contracting requirements
        [The Secretary may exempt such a contract from competitive
    contracting requirements upon adequate notice of contracting
    opportunities to individuals and organizations residing in the
    geographic vicinity of the health facility.]
        (b) Interagency Agreements.--The Secretary is authorized to
    enter into interagency agreements with other Federal agencies
    or State agencies and other entities and to accept funds from
    such Federal or State agencies or other sources to provide for
    the planning, design, and construction of health care
    facilities to be administered by Indian Health Programs in
    order to carry out the purposes of this Act and the purposes
    for which the funds were appropriated or for which the funds
    were otherwise provided.
        [(c) Consideration of individuals and organizations
        [Consideration of individuals and organizations shall be
    based solely on the qualifications established for the contract
    and the proposed contract price.]
        (c) Establishment of Standards.--The Secretary, through the
    Service, shall establish standards by regulation for the
    planning, design, and construction of health care facilities
    serving Indians under this Act.
        [(d) Liability
        [Individuals providing health care services pursuant to
    these contracts are covered by the Federal Tort Claims Act.]

    SEC. 317. AUTHORIZATION OF APPROPRIATIONS.

    [Sec. 1638d. Crediting of money collected for meals served at Indian
                        Health Service facilities]

        There are authorized to be appropriated such sums as may be
    necessary for each fiscal year through fiscal year 2017 to
    carry out this title.
        [Money heretofore and hereafter collected for meals served
    at Indian Health Service facilities will be credited to the
    appropriations from which the services were furnished and shall
    be credited to the appropriation when received.]

                      TITLE IV--ACCESS TO HEALTH SERVICES

    [Sec. 1641. Treatment of payments under medicare program]

    SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SECURITY ACT HEALTH
                        BENEFITS PROGRAMS.

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

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

              (1) Special fund.--
        [(a) Payments to special fund]
                      (A) 100 percent pass-through of payments due
                    to facilities.--Notwithstanding any other
                    provision of law, [payments to which any
                    facility of the Service (including a hospital,
                    nursing facility, intermediate care facility
                    for the mentally retarded, or any other type of
                    facility which provides services for which
                    payment is available under title XIX of the
                    Social Security Act [42 U.S.C.A. Sec. 1396 et
                    seq.]) is entitled under a State plan by reason
                    of section 1911 of such Act [42 U.S.C.A.
                    Sec. 1396j]]but subject to paragraph (2),
                    payments to which a facility of the Service is
                    entitled by reason of a provision of the Social
                    Security Act 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
                    facilities of such Service which may be
                    necessary to achieve compliance with the
                    applicable conditions and requirements of such
                    title]. In making payments from such fund, the
                    Secretary shall ensure that each [service unit]
                    Service Unit of the Service receives [at least
                    80] 100 percent of the [amounts] amount to
                    which the facilities of the Service, for which
                    such [service unit] Service Unit makes
                    collections, are entitled by reason of [section
                    1911 of the Social Security Act [42 U.S.C.A.
                    Sec. 1396j].] a provision of the Social
                    Security Act.
        [(b) Determination of appropriation
        [Any payments received by such facility for services
    provided to Indians eligible for benefits under title XIX of
    the Social Security Act [42 U.S.C.A. Sec. 1396 et seq.] shall
    not be considered in determining appropriations for the
    provision of health care and services to Indians.

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

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

    [Sec. 1644. Grants to and contracts with tribal organizations]

                      (B) Use of funds.--Amounts received by a
                    facility of the Service under subparagraph (A)
                    shall first be used (to such extent or in such
                    amounts as are provided in appropriation Acts)
                    for the purpose of making any improvements in
                    the programs of the Service operated by or
                    through such facility which may be necessary to
                    achieve or maintain compliance with the
                    applicable conditions and requirements of
                    titles XVIII and XIX of the Social Security
                    Act. Any amounts so received that are in excess
                    of the amount necessary to achieve or maintain
                    such conditions and requirements shall, subject
                    to consultation with the Indian Tribes being
                    served by the Service Unit, be used for
                    reducing the health resource deficiencies (as
                    determined under section 201(d)) of such Indian
                    Tribes.
        [(a) Access to health services
        [The Secretary, acting through the Service, shall make
    grants to or enter into contracts with tribal organizations to
    assist such organizations in establishing and administering
    programs on or near Federal Indian reservations and trust areas
    and in or near Alaska Native villages to assist individual
    Indians to--
              [(1) enroll under section 1818 of part A and sections
            1836 and 1837 of part B of title XVIII of the Social
            Security Act [42 U.S.C.A. Sec. Sec. 1395i-2, 1395o, and
            1395p];
              [(2) pay monthly premiums for coverage due to
            financial need of such individual; and
              [(3) apply for medical assistance provided pursuant
            to title XIX of the Social Security Act [42 U.S.C.A.
            Sec. 1396 et seq.].
        [(b) Terms and conditions
        [The Secretary, acting through the Service, shall place
    conditions as deemed necessary to effect the purpose of this
    section in any contract or grant which the Secretary makes with
    any tribal organization pursuant to this section. Such
    conditions shall include, but are not limited to, requirements
    that the organization successfully undertake to--
              [(1) determine the population of Indians to be served
            that are or could be recipients of benefits under
            titles XVIII and XIX of the Social Security Act [42
            U.S.C.A. Sec. Sec. 1395 et seq., 1396 et seq.];
              [(2) assist individual Indians in becoming familiar
            with and utilizing such benefits;
              [(3) provide transportation to such individual
            Indians to the appropriate offices for enrollment or
            application for medical assistance;
              [(4) develop and implement--
                      [(A) a schedule of income levels to determine
                    the extent of payments of premiums by such
                    organizations for coverage of needy
                    individuals; and
                      [(B) methods of improving the participation
                    of Indians in receiving the benefits provided
                    under titles XVIII and XIX of the Social
                    Security Act [42 U.S.C.A. Sec. Sec. 1395 et
                    seq., 1396 et seq.].
        [(c) Application for medical assistance
        [The Secretary, acting through the Service, may enter into
    an agreement with an Indian tribe, tribal organization, or
    urban Indian organization which provides for the receipt and
    processing of applications for medical assistance under title
    XIX of the Social Security Act [42 U.S.C.A. Sec. Sec. 1396 et
    seq.] and benefits under title XVIII of the Social Security Act
    [42 U.S.C.A. Sec. Sec. 1395 et seq.] at a Service facility or a
    health care facility administered by such tribe or organization
    pursuant to a contract under the Indian Self-Determination Act
    [25 U.S.C.A. Sec. 450f et seq.].
              (2) Direct payment option.--Paragraph (1) shall not
            apply to a Tribal Health Program upon the election of
            such Program under subsection (d) to receive payments
            directly. No payment may be made out of the special
            fund described in such paragraph with respect to
            reimbursement made for services provided by such
            Program during the period of such election.

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

        (d) Direct Billing.--
        [(a) Establishment of direct billing program
              [(1) In general
              [The Secretary shall establish a program under which
            Indian tribes, tribal organizations, and Alaska Native
            health organizations that contract or compact for the
            operation of a hospital or clinic of the Service under
            the Indian Self-Determination and Education Assistance
            Act]
              (1) In general.--Subject to complying with the
            requirements of paragraph (2), a Tribal Health Program
            may elect to directly bill for, and receive payment
            for, health care items and services provided by such
            [hospital or clinic] Program for which payment is made
            under title XVIII or XIX of the Social Security Act
            [(42 U.S.C. 1395 et seq.) (in this section referred to
            as the ``medicare program''), under a State plan for
            medical assistance approved under title XIX of the
            Social Security Act (42 U.S.C. 1396 et seq.) (in this
            section referred to as the ``medicaid program''),] or
            from any other third party payor.
              [(2) Application of 100 percent FMAP
              [The third sentence of section 1396d(b) of Title 42
            shall apply for purposes of reimbursement under the
            medicaid program for health care services directly
            billed under the program established under this
            section.
        [(b) Direct reimbursement
              [(1) Use of funds]
              (2) Direct reimbursement.--
              [Each hospital or clinic participating in the program
            described in subsection (a) of this section]
                      (A) Use of funds.--Each Tribal Health Program
                    making the election described in paragraph (1)
                    with respect to a program under a title of the
                    Social Security Act shall be reimbursed
                    directly [under the medicare and medicaid
                    programs for services furnished, without regard
                    to the provisions of section 1395qq(c) of Title
                    42 and sections 602(a) and 1013(b)(2)(A) of
                    Title 42, but all funds] by that program for
                    items and services furnished without regard to
                    subsection (c)(1), but all amounts so
                    reimbursed shall [first] be used by [the
                    hospital or clinic] Tribal Health Program for
                    the purpose of making any improvements in the
                    [hospital or clinic] facilities of the Tribal
                    Health Program that may be necessary to achieve
                    or maintain compliance with the conditions and
                    requirements applicable generally to
                    [facilities of such type under the medicare or
                    medicaid programs. Any funds so reimbursed
                    which are in excess of the amount necessary to
                    achieve or maintain such conditions shall be
                    used--] such items and services under the
                    program under such title and to provide
                    additional health care services, improvements
                    in health care facilities and Tribal Health
                    Programs, any health care related purpose, or
                    otherwise to achieve the objectives provided in
                    section 3 of this Act.
                      [(A) solely for improving the health
                    resources deficiency level of the Indian tribe;
                    and
                      [(B) in accordance with the regulations of
                    the Service applicable to funds provided by the
                    Service under any contract entered into under
                    the Indian Self-Determination Act (25 U.S.C.
                    450f et seq.).
              [(2) Audits
              [The amounts paid to the hospitals and clinics
            participating in the program established under this
            section]
                      (B) Audits.--The amounts paid to a Tribal
                    Health Program making the election described in
                    paragraph (1) with respect to a program under a
                    title of the Social Security Act shall be
                    subject to all auditing requirements applicable
                    to [programs administered directly by the
                    Service and to facilities participating in the
                    medicare and medicaid programs.
              [(3) Secretarial oversight
              [The Secretary shall monitor the performance of
            hospitals and clinics participating in the program
            established under this section, and shall require such
            hospitals and clinics to submit reports on the program
            to the Secretary on an annual basis.
              [(4) No payments from special funds
              [Notwithstanding section 1395qq(c) of Title 42 or
            section 602(a) of Title 42, no payment may be made out
            of the special funds described in such sections for the
            benefit of any hospital or clinic during the period
            that the hospital or clinic participates in the program
            established under this section.
        [(c) Requirements for participation
              [(1) Application
              [Except as provided in paragraph (2)(B), in order to
            be eligible for participation in the program
            established under this section, an Indian tribe, tribal
            organization, or Alaska Native health organization
            shall submit an application to the Secretary that
            establishes to the satisfaction of the [Secretary
            that--
                      [(A) the Indian tribe, tribal organization,
                    or Alaska Native health organization contracts
                    or compacts for the operation of a facility of
                    the Service;
                      [(B) the facility is eligible to participate
                    in the medicare or medicaid programs under
                    section 1395qq or 1396j of Title 42;
                      [(C) the facility meets the requirements that
                    apply to programs operated directly by the
                    Service; and
                      [(D) the facility--
                              [(i) is accredited by an accrediting
                            body as eligible for reimbursement
                            under the medicare or medicaid
                            programs; or
                              [(ii) has submitted a plan, which has
                            been approved by the Secretary, for
                            achieving such accreditation.
              [(2) Approval
                      [(A) In general
        [The Secretary shall review and approve a qualified
    application not later than 90 days after the date the
    application is submitted to the Secretary unless the Secretary
    determines that any of the criteria set forth in paragraph (1)
    are not met.
                      [(B) Grandfather of demonstration program
                    participants
        [Any participant in the demonstration program authorized
    under this section as in effect on the day before the date of
    enactment of the Alaska Native and American Indian Direct
    Reimbursement Act of 1999 shall be deemed approved for
    participation in the program established under this section and
    shall not be required to submit an application in order to
    participate in the program.
                      [(C) Duration
        [An approval by the Secretary of a qualified application
    under subparagraph (A), or a deemed approval of a demonstration
    program under subparagraph (B), shall continue in effect as
    long as the approved applicant or the deemed approved
    demonstration program meets the requirements of this section.
        [(d) Examination and implementation of changes
              [(1) In general] the program under such title, as
            well as all auditing requirements applicable to
            programs administered by an Indian Health Program.
            Nothing in the preceding sentence shall be construed as
            limiting the application of auditing requirements
            applicable to amounts paid under title XVIII, XIX, or
            XXI of the Social Security Act.
                      (C) Identification of source of payments.--
                    Any Tribal Health Program that receives
                    reimbursements or payments under title XVIII,
                    XIX, or XXI of the Social Security Act, shall
                    provide to the Service a list of each provider
                    enrollment number (or other identifier) under
                    which such Program receives such reimbursements
                    or payments.
              (3) Examination and implementation of changes._
                      (A) In general.--The Secretary, acting
                    through the Service, and with the assistance of
                    the Administrator of the [Health Care Financing
                    Administration] Centers for Medicare & Medicaid
                    Services, shall examine on an ongoing basis and
                    implement[-- (A)] any administrative changes
                    that may be necessary to facilitate direct
                    billing and reimbursement under the program
                    established under this [section] subsection,
                    including any agreements with States that may
                    be necessary to provide for direct billing
                    under the [medicaid] a program[; and] under a
                    title of the Social Security Act.
                      [(B) any changes that may be necessary to
                    enable participants in the program established
                    under this section to provide to the Service
                    medical records information on patients served
                    under the program that is consistent with the
                    medical records information system of the
                    Service.
            [(2) Accounting information
        [The accounting information that a participant in the
    program established under this section shall be required to
    report shall be the same as the information required to be
    reported by participants in the demonstration program
    authorized under this section as in effect on the day before
    the date of enactment of the Alaska Native and American Indian
    Direct Reimbursement Act of 1999. The Secretary may from time
    to time, after consultation with the program participants,
    change the accounting information submission requirements.
        [(e) Withdrawal from program]
                      (B) Coordination of information.--The Service
                    shall provide the Administrator of the Centers
                    for Medicare & Medicaid Services with copies of
                    the lists submitted to the Service under
                    paragraph (2)(C), enrollment data regarding
                    patients served by the Service (and by Tribal
                    Health Programs, to the extent such data is
                    available to the Service), and such other
                    information as the Administrator may require
                    for purposes of administering title XVIII, XIX,
                    or XXI of the Social Security Act.
        [A participant in]
              (4) Withdrawal from program.--A Tribal Health Program
            that bills directly under the program established under
            this [section] subsection may withdraw from
            participation in the same manner and under the same
            conditions that [a tribe or tribal organization] an
            Indian Tribe or Tribal Organization may retrocede a
            contracted program to the Secretary under the authority
            of the Indian Self-Determination and Education
            Assistance Act (25 U.S.C. 450 et seq.). All cost
            accounting and billing authority under the program
            established under this [section] subsection shall be
            returned to the Secretary upon the Secretary's
            acceptance of the withdrawal of participation in this
            program.
              (5) Termination for failure to comply with
            requirements.--The Secretary may terminate the
            participation of a Tribal Health Program or in the
            direct billing program established under this
            subsection if the Secretary determines that the Program
            has failed to comply with the requirements of paragraph
            (2). The Secretary shall provide a Tribal Health
            Program with notice of a determination that the Program
            has failed to comply with any such requirement and a
            reasonable opportunity to correct such noncompliance
            prior to terminating the Program's participation in the
            direct billing program established under this
            subsection.
        (e) Related Provisions Under the Social Security Act.--For
    provisions related to subsections (c) and (d), see sections
    1880, 1911, and 2107(e)(1)(D) of the Social Security Act.

    SEC. 402. GRANTS TO AND CONTRACTS WITH THE SERVICE, INDIAN TRIBES,
                        TRIBAL ORGANIZATIONS, AND URBAN INDIAN
                        ORGANIZATIONS TO FACILITATE OUTREACH, ENROLLMENT,
                        AND COVERAGE OF INDIANS UNDER SOCIAL SECURITY ACT
                        HEALTH BENEFIT PROGRAMS AND OTHER HEALTH BENEFITS
                        PROGRAMS.

        (a) Indian Tribes and Tribal Organizations.--From funds
    appropriated to carry out this title in accordance with section
    416, the Secretary, acting through the Service, shall make
    grants to or enter into contracts with Indian Tribes and Tribal
    Organizations to assist such Tribes and Tribal Organizations in
    establishing and administering programs on or near reservations
    and trust lands to assist individual Indians--
              (1) to enroll for benefits under a program
            established under title XVIII, XIX, or XXI of the
            Social Security Act and other health benefits programs;
            and
              (2) with respect to such programs for which the
            charging of premiums and cost sharing is not prohibited
            under such programs, to pay premiums or cost sharing
            for coverage for such benefits, which may be based on
            financial need (as determined by the Indian Tribe or
            Tribes or Tribal Organizations being served based on a
            schedule of income levels developed or implemented by
            such Tribe, Tribes, or Tribal Organizations).
        (b) Conditions.--The Secretary, acting through the Service,
    shall place conditions as deemed necessary to effect the
    purpose of this section in any grant or contract which the
    Secretary makes with any Indian Tribe or Tribal Organization
    pursuant to this section. Such conditions shall include
    requirements that the Indian Tribe or Tribal Organization
    successfully undertake--
              (1) to determine the population of Indians eligible
            for the benefits described in subsection (a);
              (2) to educate Indians with respect to the benefits
            available under the respective programs;
              (3) to provide transportation for such individual
            Indians to the appropriate offices for enrollment or
            applications for such benefits; and
              (4) to develop and implement methods of improving the
            participation of Indians in receiving benefits under
            such programs.
        (c) Application to Urban Indian Organizations.--
              (1) In general.--The provisions of subsection (a)
            shall apply with respect to grants and other funding to
            Urban Indian Organizations with respect to populations
            served by such organizations in the same manner they
            apply to grants and contracts with Indian Tribes and
            Tribal Organizations with respect to programs on or
            near reservations.
              (2) Requirements.--The Secretary shall include in the
            grants or contracts made or provided under paragraph
            (1) requirements that are--
                      (A) consistent with the requirements imposed
                    by the Secretary under subsection (b);
                      (B) appropriate to Urban Indian Organizations
                    and Urban Indians; and
                      (C) necessary to effect the purposes of this
                    section.
        (d) Facilitating Cooperation.--The Secretary, acting
    through the Centers for Medicare & Medicaid Services, shall
    take such steps as are necessary to facilitate cooperation
    with, and agreements between, States and the Service, Indian
    Tribes, Tribal Organizations, or Urban Indian Organizations
    with respect to the provision of health care items and services
    to Indians under the programs established under title XVIII,
    XIX, or XXI of the Social Security Act.
        (e) Agreements Relating to Improving Enrollment of Indians
    Under Social Security Act Health Benefits Programs.--For
    provisions relating to agreements between the Secretary, acting
    through the Service, and Indian Tribes, Tribal Organizations,
    and Urban Indian Organizations for the collection, preparation,
    and submission of applications by Indians for assistance under
    the Medicaid and State children's health insurance programs
    established under titles XIX and XXI of the Social Security
    Act, and benefits under the Medicare program established under
    title XVIII of such Act, see subsections (a) and (b) of section
    1139 of the Social Security Act.
        (f) Definition of Premiums and Cost Sharing.--In this
    section:
              (1) Premium.--The term ``premium'' includes any
            enrollment fee or similar charge.
              (2) Cost sharing.--The term ``cost sharing'' includes
            any deduction, deductible, copayment, coinsurance, or
            similar charge.

    SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PARTIES OF COSTS OF HEALTH
                        SERVICES.

        (a) Right of Recovery.--Except as provided in subsection
    (f), the United States, an Indian Tribe, or Tribal Organization
    shall have the right to recover from an insurance company,
    health maintenance organization, employee benefit plan, third-
    party tortfeasor, or any other responsible or liable third
    party (including a political subdivision or local governmental
    entity of a State) the reasonable charges billed by the
    Secretary, an Indian Tribe, or Tribal Organization in providing
    health services through the Service, an Indian Tribe, or Tribal
    Organization to any individual to the same extent that such
    individual, or any nongovernmental provider of such services,
    would be eligible to receive damages, reimbursement, or
    indemnification for such charges or expenses if--
              (1) such services had been provided by a
            nongovernmental provider; and
              (2) such individual had been required to pay such
            charges or expenses and did pay such charges or
            expenses.
        (b) Limitations on Recoveries From States.--Subsection (a)
    shall provide a right of recovery against any State, only if
    the injury, illness, or disability for which health services
    were provided is covered under--
              (1) workers' compensation laws; or
              (2) a no-fault automobile accident insurance plan or
            program.
        (c) Nonapplication of Other Laws.--No law of any State, or
    of any political subdivision of a State and no provision of any
    contract, insurance or health maintenance organization policy,
    employee benefit plan, self-insurance plan, managed care plan,
    or other health care plan or program entered into or renewed
    after the date of the enactment of the Indian Health Care
    Amendments of 1988, shall prevent or hinder the right of
    recovery of the United States, an Indian Tribe, or Tribal
    Organization under subsection (a).
        (d) No Effect on Private Rights of Action.--No action taken
    by the United States, an Indian Tribe, or Tribal Organization
    to enforce the right of recovery provided under this section
    shall operate to deny to the injured person the recovery for
    that portion of the person's damage not covered hereunder.
        (e) Enforcement.--
              (1) In general.--The United States, an Indian Tribe,
            or Tribal Organization may enforce the right of
            recovery provided under subsection (a) by--
                      (A) intervening or joining in any civil
                    action or proceeding brought--
                              (i) by the individual for whom health
                            services were provided by the
                            Secretary, an Indian Tribe, or Tribal
                            Organization; or
                              (ii) by any representative or heirs
                            of such individual, or
                      (B) instituting a civil action, including a
                    civil action for injunctive relief and other
                    relief and including, with respect to a
                    political subdivision or local governmental
                    entity of a State, such an action against an
                    official thereof.
              (2) Notice.--All reasonable efforts shall be made to
            provide notice of action instituted under paragraph
            (1)(B) to the individual to whom health services were
            provided, either before or during the pendency of such
            action.
              (3) Recovery from tortfeasors.--
                      (A) In general.--In any case in which an
                    Indian Tribe or Tribal Organization that is
                    authorized or required under a compact or
                    contract issued pursuant to the Indian Self-
                    Determination and Education Assistance Act (25
                    U.S.C. 450 et seq.) to furnish or pay for
                    health services to a person who is injured or
                    suffers a disease on or after the date of
                    enactment of the Indian Health Care Improvement
                    Act Amendments of 2007 under circumstances that
                    establish grounds for a claim of liability
                    against the tortfeasor with respect to the
                    injury or disease, the Indian Tribe or Tribal
                    Organization shall have a right to recover from
                    the tortfeasor (or an insurer of the
                    tortfeasor) the reasonable value of the health
                    services so furnished, paid for, or to be paid
                    for, in accordance with the Federal Medical
                    Care Recovery Act (42 U.S.C. 2651 et seq.), to
                    the same extent and under the same
                    circumstances as the United States may recover
                    under that Act.
                      (B) Treatment.--The right of an Indian Tribe
                    or Tribal Organization to recover under
                    subparagraph (A) shall be independent of the
                    rights of the injured or diseased person served
                    by the Indian Tribe or Tribal Organization.
        (f) Limitation.--Absent specific written authorization by
    the governing body of an Indian Tribe for the period of such
    authorization (which may not be for a period of more than 1
    year and which may be revoked at any time upon written notice
    by the governing body to the Service), the United States shall
    not have a right of recovery under this section if the injury,
    illness, or disability for which health services were provided
    is covered under a self-insurance plan funded by an Indian
    Tribe, Tribal Organization, or Urban Indian Organization. Where
    such authorization is provided, the Service may receive and
    expend such amounts for the provision of additional health
    services consistent with such authorization.
        (g) Costs and Attorneys' Fees.--In any action brought to
    enforce the provisions of this section, a prevailing plaintiff
    shall be awarded its reasonable attorneys' fees and costs of
    litigation.
        (h) Nonapplication of Claims Filing Requirements.--An
    insurance company, health maintenance organization, self-
    insurance plan, managed care plan, or other health care plan or
    program (under the Social Security Act or otherwise) may not
    deny a claim for benefits submitted by the Service or by an
    Indian Tribe or Tribal Organization based on the format in
    which the claim is submitted if such format complies with the
    format required for submission of claims under title XVIII of
    the Social Security Act or recognized under section 1175 of
    such Act.
        (i) Application to Urban Indian Organizations.--The
    previous provisions of this section shall apply to Urban Indian
    Organizations with respect to populations served by such
    Organizations in the same manner they apply to Indian Tribes
    and Tribal Organizations with respect to populations served by
    such Indian Tribes and Tribal Organizations.
        (j) Statute of Limitations.--The provisions of section 2415
    of title 28, United States Code, shall apply to all actions
    commenced under this section, and the references therein to the
    United States are deemed to include Indian Tribes, Tribal
    Organizations, and Urban Indian Organizations.
        (k) Savings.--Nothing in this section shall be construed to
    limit any right of recovery available to the United States, an
    Indian Tribe, or Tribal Organization under the provisions of
    any applicable, Federal, State, or Tribal law, including
    medical lien laws.

    SEC. 404. CREDITING OF REIMBURSEMENTS.

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

    SEC. 405. PURCHASING HEALTH CARE COVERAGE.

        (a) In General.--Insofar as amounts are made available
    under law (including a provision of the Social Security Act,
    the Indian Self-Determination and Education Assistance Act (25
    U.S.C. 450 et seq.), or other law, other than under section
    402) to Indian Tribes, Tribal Organizations, and Urban Indian
    Organizations for health benefits for Service beneficiaries,
    Indian Tribes, Tribal Organizations, and Urban Indian
    Organizations may use such amounts to purchase health benefits
    coverage for such beneficiaries in any manner, including
    through--
              (1) a tribally owned and operated health care plan;
              (2) a State or locally authorized or licensed health
            care plan;
              (3) a health insurance provider or managed care
            organization; or
              (4) a self-insured plan.
        The purchase of such coverage by an Indian Tribe, Tribal
    Organization, or Urban Indian Organization may be based on the
    financial needs of such beneficiaries (as determined by the
    Indian Tribe or Tribes being served based on a schedule of
    income levels developed or implemented by such Indian Tribe or
    Tribes).
        (b) Expenses for Self-Insured Plan.--In the case of a self-
    insured plan under subsection (a)(4), the amounts may be used
    for expenses of operating the plan, including administration
    and insurance to limit the financial risks to the entity
    offering the plan.
        (c) Construction.--Nothing in this section shall be
    construed as affecting the use of any amounts not referred to
    in subsection (a).

    SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGENCIES.

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

    SEC. 407. PAYOR OF LAST RESORT.

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

    SEC. 408. NONDISCRIMINATION UNDER FEDERAL HEALTH CARE PROGRAMS IN
                        QUALIFICATIONS FOR REIMBURSEMENT FOR SERVICES.

        (a) Requirement To Satisfy Generally Applicable
    Participation Requirements.--
              (1) In general.--A Federal health care program must
            accept an entity that is operated by the 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.
              (2) 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 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, 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.
        (b) Application of Exclusion From Participation in Federal
    Health Care Programs.--
              (1) Excluded entities.--No entity operated by the
            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 or reimbursement under any
            such program for health care services furnished to an
            Indian.
              (2) Excluded individuals.--No individual who has been
            excluded from participation in any Federal health care
            program or whose State license is under suspension
            shall be eligible to receive payment or reimbursement
            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.
              (3) Federal health care program defined.--In this
            subsection, the term, `Federal health care program' has
            the meaning given that term in section 1128B(f) of the
            Social Security Act (42 U.S.C. 1320a-7b(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.
              (c) Related provisions.--For provisions related to
            nondiscrimination against providers operated by the
            Service, an Indian Tribe, Tribal Organization, or Urban
            Indian Organization, see section 1139(c) of the Social
            Security Act (42 U.S.C. 1320b-9(c)).

    SEC. 409. CONSULTATION.

        For provisions related to consultation with representatives
    of Indian Health Programs and Urban Indian Organizations with
    respect to the health care programs established under titles
    XVIII, XIX, and XXI of the Social Security Act, see section
    1139(d) of the Social Security Act (42 U.S.C. 1320b-9(d)).

    SEC. 410. STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP).

        For provisions relating to--
              (1) outreach to families of Indian children likely to
            be eligible for child health assistance under the State
            children's health insurance program established under
            title XXI of the Social Security Act, see sections
            2105(c)(2)(C) and 1139(a) of such Act (42 U.S.C.
            1397ee(c)(2), 1320b-9); and
              (2) ensuring that child health assistance is provided
            under such program to targeted low-income children who
            are Indians and that payments are made under such
            program to Indian Health Programs and Urban Indian
            Organizations operating in the State that provide such
            assistance, see sections 2102(b)(3)(D) and
            2105(c)(6)(B) of such Act (42 U.S.C. 1397bb(b)(3)(D),
            1397ee(c)(6)(B)).

    SEC. 411. EXCLUSION WAIVER AUTHORITY FOR AFFECTED INDIAN HEALTH
                        PROGRAMS AND SAFE HARBOR TRANSACTIONS UNDER THE
                        SOCIAL SECURITY ACT.

        For provisions relating to--
              (1) exclusion waiver authority for affected Indian
            Health Programs under the Social Security Act, see
            section 1128(k) of the Social Security Act (42 U.S.C.
            1320a-7(k)); and
              (2) certain transactions involving Indian Health
            Programs deemed to be in safe harbors under that Act,
            see section 1128B(b)(4) of the Social Security Act (42
            U.S.C. 1320a-7b(b)(4)).

    SEC. 412. PREMIUM AND COST SHARING PROTECTIONS AND ELIGIBILITY
                        DETERMINATIONS UNDER MEDICAID AND SCHIP AND
                        PROTECTION OF CERTAIN INDIAN PROPERTY FROM MEDICAID
                        ESTATE RECOVERY.

        For provisions relating to--
              (1) premiums or cost sharing protections for Indians
            furnished items or services directly by Indian Health
            Programs or through referral under the contract health
            service under the Medicaid program established under
            title XIX of the Social Security Act, see sections
            1916(j) and 1916A(a)(1) of the Social Security Act (42
            U.S.C. 1396o(j), 1396o-1(a)(1));
              (2) rules regarding the treatment of certain property
            for purposes of determining eligibility under such
            programs, see sections 1902(e)(13) and 2107(e)(1)(B) of
            such Act (42 U.S.C. 1396a(e)(13), 1397gg(e)(1)(B)); and
              (3) the protection of certain property from estate
            recovery provisions under the Medicaid program, see
            section 1917(b)(3)(B) of such Act (42 U.S.C.
            1396p(b)(3)(B)).

    SEC. 413. TREATMENT UNDER MEDICAID AND SCHIP MANAGED CARE.

        For provisions relating to the treatment of Indians
    enrolled in a managed care entity under the Medicaid program
    under title XIX of the Social Security Act and Indian Health
    Programs and Urban Indian Organizations that are providers of
    items or services to such Indian enrollees, see sections
    1932(h) and 2107(e)(1)(H) of the Social Security Act (42 U.S.C.
    1396u-2(h), 1397gg(e)(1)(H)).

    SEC. 414. NAVAJO NATION MEDICAID AGENCY FEASIBILITY STUDY.

        (a) Study.--The Secretary shall conduct a study to
    determine the feasibility of treating the Navajo Nation as a
    State for the purposes of title XIX of the Social Security Act,
    to provide services to Indians living within the boundaries of
    the Navajo Nation through an entity established having the same
    authority and performing the same functions as single-State
    medicaid agencies responsible for the administration of the
    State plan under title XIX of the Social Security Act.
        (b) Considerations.--In conducting the study, the Secretary
    shall consider the feasibility of--
              (1) assigning and paying all expenditures for the
            provision of services and related administration funds,
            under title XIX of the Social Security Act, to Indians
            living within the boundaries of the Navajo Nation that
            are currently paid to or would otherwise be paid to the
            State of Arizona, New Mexico, or Utah;
              (2) providing assistance to the Navajo Nation in the
            development and implementation of such entity for the
            administration, eligibility, payment, and delivery of
            medical assistance under title XIX of the Social
            Security Act;
              (3) providing an appropriate level of matching funds
            for Federal medical assistance with respect to amounts
            such entity expends for medical assistance for services
            and related administrative costs; and
              (4) authorizing the Secretary, at the option of the
            Navajo Nation, to treat the Navajo Nation as a State
            for the purposes of title XIX of the Social Security
            Act (relating to the State children's health insurance
            program) under terms equivalent to those described in
            paragraphs (2) through (4).
        (c) Report.--Not later than 3 years after the date of
    enactment of the Indian Health Care Improvement Act Amendments
    of 2007, the Secretary shall submit to the Committee on Indian
    Affairs and Committee on Finance of the Senate and the
    Committee on Natural Resources and Committee on Energy and
    Commerce of the House of Representatives a report that
    includes--
              (1) the results of the study under this section;
              (2) a summary of any consultation that occurred
            between the Secretary and the Navajo Nation, other
            Indian Tribes, the States of Arizona, New Mexico, and
            Utah, counties which include Navajo Lands, and other
            interested parties, in conducting this study;
              (3) projected costs or savings associated with
            establishment of such entity, and any estimated impact
            on services provided as described in this section in
            relation to probable costs or savings; and
              (4) legislative actions that would be required to
            authorize the establishment of such entity if such
            entity is determined by the Secretary to be feasible.

    [Sec. 1646. Authorization for emergency contract health services]

    SEC. 415. GENERAL EXCEPTIONS.

        [With respect to an elderly or disabled Indian receiving
    emergency medical care or services from a non-Service provider
    or in a non-Service facility under the authority of this Act,
    the time limitation (as a condition of payment) for notifying
    the Service of such treatment or admission shall be 30 days.]
        The requirements of this title shall not apply to any
    excepted benefits described in paragraph (1)(A) or (3) of
    section 2791(c) of the Public Health Service Act (42 U.S.C.
    300gg-91).

    [Sec. 1647. Authorization of appropriations]

    SEC. 416. AUTHORIZATION OF APPROPRIATIONS.

        There are authorized to be appropriated such sums as may be
    necessary for each fiscal year through fiscal year [2000] 2017
    to carry out this [subchapter] title.

                   TITLE V--HEALTH SERVICES FOR URBAN INDIANS

    [Sec. 1651. Purpose]

    SEC. 501. PURPOSE.

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

    [Sec. 1652. Contracts with, and grants to, urban Indian organizations]

    SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN INDIAN ORGANIZATIONS.

        Under authority of the Act of November 2, 1921 (25 U.S.C.
    13), [popularly] (commonly known as the ``Snyder Act''), the
    Secretary, acting through the Service, shall enter into
    contracts with, or make grants to, [urban] Urban Indian
    [organizations] Organizations to assist such organizations in
    the establishment and administration, within [the urban centers
    in which such organizations are situated] Urban Centers, of
    programs which meet the requirements set forth in this
    [subchapter. The] title. Subject to section 506, the Secretary,
    acting through the Service, shall include such conditions as
    the Secretary considers necessary to effect the purpose of this
    [subchapter] title in any contract into which the Secretary
    enters [into] with, or in any grant the Secretary makes to, any
    [urban] Urban Indian [organization] Organization pursuant to
    this [subchapter] title.

    [Sec. 1653. Contracts and grants for the provision of health care and
                        referral services]

    SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION OF HEALTH CARE AND
                        REFERRAL SERVICES.

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

    SEC. 504. CONTRACTS AND GRANTS FOR THE DETERMINATION OF UNMET HEALTH
                        CARE NEEDS.

                      [(C) the assessment required under paragraph
                    (2).]

    [Sec. 1654. Contracts and grants for determination of unmet health care
                        needs]

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

    SEC. 505. EVALUATIONS; RENEWALS.

        [Sec. 1655.] (a) Procedures for Evaluations[; renewals]
        [(a) Contract compliance and performance].--The Secretary,
    acting through the Service, shall develop procedures to
    evaluate compliance with grant requirements [under this
    subchapter] and compliance with[,] and performance of contracts
    entered into by [urban] Urban Indian [organizations]
    Organizations under this [subchapter] title. Such procedures
    shall include provisions for carrying out the requirements of
    this section.
        [(b) Annual onsite evaluation]
        (b) Evaluations.--The Secretary, acting through the
    Service, shall [conduct an annual onsite evaluation of each
    urban Indian organization] evaluate the compliance of each
    Urban Indian Organization which has entered into a contract or
    received a grant under section [1653 of this title for purposes
    of determining the compliance of such organization with, and
    evaluating the performance of such organization under, such
    contract or the terms of such] 503 with the terms of such
    contract or grant. For purposes of this evaluation, the
    Secretary shall--
              (1) acting through the Service, conduct an annual
            onsite evaluation of the organization; or
              (2) accept in lieu of such onsite evaluation evidence
            of the organization's provisional or full accreditation
            by a private independent entity recognized by the
            Secretary for purposes of conducting quality reviews of
            providers participating in the Medicare program under
            title XVIII of the Social Security Act.
        (c) Noncompliance [or unsatisfactory performance];
    Unsatisfactory Performance.--If, as a result of the evaluations
    conducted under this section, the Secretary determines that an
    [urban] Urban Indian [organization] Organization has not
    complied with the requirements of a grant or complied with or
    satisfactorily performed a contract under section [1653 of this
    title,] 503, the Secretary shall, prior to renewing such
    contract or grant, attempt to resolve with [such] the
    organization the areas of noncompliance or unsatisfactory
    performance and modify [such] the contract or grant to prevent
    future occurrences of [such] noncompliance or unsatisfactory
    performance. If the Secretary determines that [such] the
    noncompliance or unsatisfactory performance cannot be resolved
    and prevented in the future, the Secretary shall not renew
    [such] the contract or grant with [such] the organization and
    is authorized to enter into a contract or make a grant under
    section [1653 of this title] 503 with another [urban] Urban
    Indian [organization] Organization which is situated in the
    same [urban center] Urban Center as the [urban] Urban Indian
    [organization] Organization whose contract or grant is not
    renewed under this section.
        [(d) Contract and grant renewals]
        (d) Considerations for Renewals.--In determining whether to
    renew a contract or grant with an [urban] Urban Indian
    [organization] Organization under section [1653 of this title]
    503 which has completed performance of a contract or grant
    under section [1654 of this title,] 504, the Secretary shall
    review the records of the [urban] Urban Indian [organization]
    Organization, the reports submitted under section [1657 of this
    title, and, in the case of a renewal of a contract or grant
    under section 1653 of this title,] 507, and shall consider the
    results of the onsite evaluations [conducted] or accreditations
    under subsection (b) [of this section].

    [Sec. 1656. Other contract and grant requirements]

    SEC. 506. OTHER CONTRACT AND GRANT REQUIREMENTS.

        [(a) Federal regulations; exceptions]
        (a) Procurement.--Contracts with [urban Indian
    organizations] Urban Indian Organizations entered into pursuant
    to this [subchapter] title shall be in accordance with all
    Federal contracting laws and regulations relating to
    procurement except that, in the discretion of the Secretary,
    such contracts may be negotiated without advertising and need
    not conform to the provisions of [the Act of August 24, 1935
    (40 U.S.C 270a, et seq.).] sections 1304 and 3131 through 3133
    of title 40, United States Code.
        [(b) Payment]
        (b) Payments Under Contracts or Grants.--
              (1) In general.--Payments under any contracts or
            grants pursuant to this [subchapter may be made in
            advance or by way of reimbursement and in such
            installments and on such conditions as the Secretary
            deems necessary to carry out the purposes of this
            subchapter.] title, notwithstanding any term or
            condition of such contract or grant--
                      (A) may be made in a single advance payment
                    by the Secretary to the Urban Indian
                    Organization by no later than the end of the
                    first 30 days of the funding period with
                    respect to which the payments apply, unless the
                    Secretary determines through an evaluation
                    under section 505 that the organization is not
                    capable of administering such a single advance
                    payment; and
                      (B) if any portion thereof is unexpended by
                    the Urban Indian Organization during the
                    funding period with respect to which the
                    payments initially apply, shall be carried
                    forward for expenditure with respect to
                    allowable or reimbursable costs incurred by the
                    organization during 1 or more subsequent
                    funding periods without additional
                    justification or documentation by the
                    organization as a condition of carrying forward
                    the availability for expenditure of such funds.
              (2) Semiannual and quarterly payments and
            reimbursements.--If the Secretary determines under
            paragraph (1)(A) that an Urban Indian organization is
            not capable of administering an entire single advance
            payment, on request of the Urban Indian Organization,
            the payments may be made--
                      (A) in semiannual or quarterly payments by
                    not later than 30 days after the date on which
                    the funding period with respect to which the
                    payments apply begins; or
                      (B) by way of reimbursement.
          (c) Revision or [amendment] Amendment of Contracts.--
    Notwithstanding any provision of law to the contrary, the
    Secretary may, at the request [or] and consent of an [urban]
    Urban Indian [organization] Organization, revise or amend any
    contract entered into by the Secretary with such organization
    under this [subchapter] title as necessary to carry out the
    purposes of this [subchapter] title.
        [(d) Existing Government facilities]
        [In connection with any contract or grant entered into
    pursuant to this subchapter, the Secretary may permit an urban
    Indian organization to utilize, in carrying out such contract
    or grant, existing facilities owned by the Federal Government
    within the Secretary's jurisdiction under such terms and
    conditions as may be agreed upon for the use and maintenance of
    such facilities.]
        [(e)] (d) Fair and Uniform [provision of services and
    assistance] Services and Assistance.--Contracts with, or grants
    to[, urban] Urban Indian [organizations] Organizations and
    regulations adopted pursuant to this [subchapter] title shall
    include provisions to assure the fair and uniform provision to
    [urban] Urban Indians of services and assistance under such
    contracts or grants by such organizations.
        [(f) Eligibility for health care or referral services
        [Urban Indians, as defined in section 1603(f) of this
    title, shall be eligible for health care or referral services
    provided pursuant to this subchapter.]

    SEC. 507. REPORTS AND RECORDS.

        [Sec. 1657.] (a) Reports [and records].--
        [(a) Quarterly reports]
              (1) In general.--For each fiscal year during which an
            [urban] Urban Indian [organization] Organization
            receives or expends funds pursuant to a contract
            entered into[,] or a grant received[,] pursuant to this
            [subchapter] title, such [organization] Urban Indian
            Organization shall submit to the Secretary [a quarterly
            report including--] not more frequently than every 6
            months, a report that includes the following:
                      [(1)] (A) [in] In the case of a contract or
                    grant under section [1653 of this title,
                    information gathered pursuant to clauses (10)
                    and (11) of subsection (a) of such section;]
                    503, recommendations pursuant to section
                    503(a)(5).
                      [(2) information] (B) Information on
                    activities conducted by the organization
                    pursuant to the contract or grant[;].
                      [(3)] (C) [an] An accounting of the amounts
                    and [purposes] purpose for which Federal funds
                    were expended[; and].
                      [(4) such other information as the Secretary
                    may request.]
                      (D) A minimum set of data, using uniformly
                    defined elements, as specified by the Secretary
                    after consultation with Urban Indian
                    Organizations.
              (2) Health status and services.--
                      (A) In general.--Not later than 18 months
                    after the date of enactment of the Indian
                    Health Care Improvement Act Amendments of 2007,
                    the Secretary, acting through the Service,
                    shall submit to Congress a report evaluating--
                              (i) the health status of Urban
                            Indians;
                              (ii) the services provided to Indians
                            pursuant to this title; and
                              (iii) areas of unmet needs in the
                            delivery of health services to Urban
                            Indians.
                      (B) Consultation and contracts.--In preparing
                    the report under paragraph (1), the Secretary--
                              (i) shall consult with Urban Indian
                            Organizations; and
                              (ii) may enter into a contract with a
                            national organization representing
                            Urban Indian Organizations to conduct
                            any aspect of the report.
        (b) Audit [by Secretary and Comptroller General].--The
    reports and records of the [urban] Urban Indian [organization]
    Organization with respect to a contract or grant under this
    [subchapter] title shall be subject to audit by the Secretary
    and the Comptroller General of the United States.
        (c) [Cost] Costs of [annual private audit] Audits.--The
    Secretary shall allow as a cost of any contract or grant
    entered into or awarded under section [1653 of this title] 502
    or 503 the cost of an annual [private] independent financial
    audit conducted by--
              (1) a certified public accountant[.] ; or
        [(d) Health status, services, and areas of unmet needs;
    child welfare
              [(1) The Secretary, acting through the Service, shall
            submit a report to the Congress not later than March
            31, 1992, evaluating--
                      [(A) the health status of urban Indians;
                      [(B) the services provided to Indians through
                    this subchapter;
                      [(C) areas of unmet needs in urban areas
                    served under this subchapter; and
                      [(D) areas of unmet needs in urban areas not
                    served under this subchapter.
              [(2) In preparing the report under paragraph (1), the
            Secretary shall consult with urban Indian health
            providers and may contract with a national organization
            representing urban Indian health concerns to conduct
            any aspect of the report.
              [(3) The Secretary and the Secretary of the Interior,
            shall]
              (2) a certified public accounting firm qualified to
            conduct Federal compliance audits.

    SEC. 508. LIMITATION ON CONTRACT AUTHORITY.

                      [(A) assess the status of the welfare of
                    urban Indian children, including the volume of
                    child protection cases, the prevalence of child
                    sexual abuse, and the extent of urban Indian
                    coordination with tribal authorities with
                    respect to child sexual abuse; and
                      [(B) submit a report on the assessment
                    required under subparagraph (A), together with
                    recommended legislation to improve Indian child
                    protection in urban Indian populations, to the
                    Congress no later than March 31, 1992.]

    [Sec. 1658. Limitation on contract authority]

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

    [Sec. 1659. Facilities renovation]

    SEC. 509. FACILITIES.

        (a) Grants.--The Secretary, acting through the Service, may
    make [funds available] grants to contractors or grant
    recipients under this [subchapter for minor renovations to]
    title for the lease, purchase, renovation, construction, or
    expansion of facilities, including leased facilities, in order
    to assist such contractors or grant recipients in [meeting or
    maintaining the Joint Commission for Accreditation of Health
    Care Organizations (JCAHO) standards] complying with applicable
    licensure or certification requirements.
        (b) Loan Fund Study.--The Secretary, acting through the
    Service, may carry out a study to determine the feasibility of
    establishing a loan fund to provide to Urban Indian
    Organizations direct loans or guarantees for loans for the
    construction of health care facilities in a manner consistent
    with section 309, including by submitting a report in
    accordance with subsection (c) of that section.

    [Sec. 1660. Urban Health Programs Branch]

    SEC. 510. DIVISION OF URBAN INDIAN HEALTH.

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

    [Sec. 1660a. Grants for alcohol and substance abuse related services

    SEC. 511. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE-RELATED SERVICES.

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

    [Sec. 1660b. Treatment of certain demonstration projects]

    SEC. 512. TREATMENT OF CERTAIN DEMONSTRATION PROJECTS.

        [(a)] Notwithstanding any other provision of law, the Tulsa
    Clinic and Oklahoma City Clinic demonstration [project and the
    Tulsa Clinic demonstration project shall be treated as service
    units] projects shall--
              (1) be permanent programs within the Service's direct
            care program;
              (2) continue to be treated as Service Units and
            Operating Units in the allocation of resources and
            coordination of care; and
              (3) continue to meet the requirements and definitions
            of an Urban Indian Organization in this Act, and shall
            not be subject to the provisions of the Indian Self-
            Determination and Education Assistance Act [[](25
            U.S.C.[A. Sec. 450f et seq.] for the term of such
            projects. The Secretary shall provide assistance to
            such projects in the development of resources and
            equipment and facility needs.] 450 et seq.).
        [(b) The Secretary shall submit to the President, for
    inclusion in the report required to be submitted to the
    Congress under section 1671 of this title for fiscal year 1999,
    a report on the findings and conclusions derived from the
    demonstration projects specified in subsection (a) of this
    section.
        [(c) In addition to the amounts made available under
    section 1660d of this title to carry out this section through
    fiscal year 2000, there are authorized to be appropriated such
    sums as may be necessary to carry out this section for each of
    fiscal years 2001 and 2002.]

    [Sec. 1660c. Urban NIAAA transferred programs]

    SEC. 513. URBAN NIAAA TRANSFERRED PROGRAMS.

        [(a) Duty of Secretary
        [The Secretary shall, within]
        (a) Grants and Contracts.--The Secretary, through the
    [Branch] Division of Urban [Health Programs of the Service,]
    Indian Health, shall make grants or enter into contracts with
    Urban Indian Organizations, to take effect not later than
    September 30, 2010, for the administration of [urban] Urban
    Indian alcohol programs that were originally established under
    the National Institute on Alcoholism and Alcohol Abuse
    (hereafter in this section referred to as ``NIAAA'') and
    transferred to the Service.
        (b) Use of [grants] Funds.--Grants provided or contracts
    entered into under this section shall be used to provide
    support for the continuation of alcohol prevention and
    treatment services for [urban] Urban Indian populations and
    such other objectives as are agreed upon between the Service
    and a recipient of a grant or contract under this section.
        (c) Eligibility [for grants].--Urban Indian [organizations]
    Organizations that operate Indian alcohol programs originally
    funded under the NIAAA and subsequently transferred to the
    Service are eligible for grants or contracts under this
    section.
        [(d) Combination of funds
        [For the purpose of carrying out this section, the
    Secretary may combine NIAAA alcohol funds with other substance
    abuse funds currently administered through the Branch of Urban
    Health Programs of the Service.
        [(e) Evaluation and report to Congress]
        (d) Report.--The Secretary shall evaluate and report to
    [the] Congress on the activities of programs funded under this
    section [at least] not less than every 5 years.

    SEC. 514. CONSULTATION WITH URBAN INDIAN ORGANIZATIONS.

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

    SEC. 515. URBAN YOUTH TREATMENT CENTER DEMONSTRATION.

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

    SEC. 516. GRANTS FOR DIABETES PREVENTION, TREATMENT, AND CONTROL.

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

    SEC. 517. COMMUNITY HEALTH REPRESENTATIVES.

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

    SEC. 518. EFFECTIVE DATE.

        The amendments made by the Indian Health Care Improvement
    Act Amendments of 2007 to this title shall take effect
    beginning on the date of enactment of that Act, regardless of
    whether the Secretary has promulgated regulations implementing
    such amendments.

    SEC. 519. ELIGIBILITY FOR SERVICES.

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

    [Sec. 1660d. Authorization of appropriations]

    SEC. 520. AUTHORIZATION OF APPROPRIATIONS.

        There are authorized to be appropriated such sums as may be
    necessary for each fiscal year through fiscal year [2000] 2017
    to carry out this [subchapter] title.

                     TITLE VI--ORGANIZATIONAL IMPROVEMENTS

    [Sec. 1661. Establishment of the Indian Health Service as an agency of
                        Public Health Service]

    SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERVICE AS AN AGENCY OF
                        THE PUBLIC HEALTH SERVICE.

        (a) Establishment.--
              (1) In general._In order to more effectively and
            efficiently carry out the responsibilities,
            authorities, and functions of the United States to
            provide health care services to Indians and Indian
            [tribes] Tribes, as are or may be [on and after
            November 23, 1988,] hereafter provided by Federal
            statute or treaties, there is established within the
            Public Health Service of the Department [of Health and
            Human Services] the Indian Health Service.
              (2) Assistant secretary for indian health._The
            [Indian Health] Service shall be administered by [a
            Director] an Assistant Secretary for Indian Health, who
            shall be appointed by the President, by and with the
            advice and consent of the Senate. The [Director of the
            Indian Health Service] Assistant Secretary shall report
            to the Secretary [through the Assistant Secretary for
            Health of the Department of Health and Human Services].
            Effective with respect to an individual appointed by
            the President, by and with the advice and consent of
            the Senate, after January 1, [1993,] 2007, the term of
            service of the [Director] Assistant Secretary shall be
            4 years. [A Director] An Assistant Secretary may serve
            more than 1 term.
              (3) Incumbent.--The individual serving in the
            position of Director of the Service on the day before
            the date of enactment of the Indian Health Care
            Improvement Act Amendments of 2007 shall serve as
            Assistant Secretary.
              (4) Advocacy and consultation.--The position of
            Assistant Secretary is established to, in a manner
            consistent with the government-to-government
            relationship between the United States and Indian
            Tribes--
                      (A) facilitate advocacy for the development
                    of appropriate Indian health policy; and
                      (B) promote consultation on matters relating
                    to Indian health.
        (b) Agency.--[status] The [Indian Health]Service shall be
    an agency within the Public Health Service of the Department
    [of Health and Human Services], and shall not be an office,
    component, or unit of any other agency of the Department.
        (c) Duties.--The Assistant Secretary shall [carry out
    through the Director of the Indian Health Service]--
              (1) perform all functions [which] that were, on the
            day before [November 23, 1988,] the date of enactment
            of the Indian Health Care Improvement Act Amendments of
            2007, carried out by or under the direction of the
            individual serving as Director of the [Indian
            Health]Service on[such] that day;
              (2) perform all functions of the Secretary relating
            to the maintenance and operation of hospital and health
            facilities for Indians and the planning for, and
            provision and utilization of, health services for
            Indians;
              (3) administer all health programs under which health
            care is provided to Indians based upon their status as
            Indians which are administered by the Secretary,
            including[(but not limited to)]programs under--
                      (A) this[chapter] Act;
                      (B) the Act of November 2, 1921 (25 U.S.C.
                    13);
                      (C) the Act of August 5, 1954 (42 U.S.C.
                    [2001,] 2001 et seq.);
                      (D) the Act of August 16, 1957 (42 U.S.C.
                    2005 et seq.); and
                      (E) the Indian Self-Determination and
                    Education Assistance Act (25 U.S.C. 450[f] et
                    seq.); [and]
              (4) administer all scholarship and loan functions
            carried out under [subchapter I of this chapter.] title
            I;
              (5) report directly to the Secretary concerning all
            policy- and budget-related matters affecting Indian
            health;
              (6) collaborate with the Assistant Secretary for
            Health concerning appropriate matters of Indian health
            that affect the agencies of the Public Health Service;
              (7) advise each Assistant Secretary of the Department
            concerning matters of Indian health with respect to
            which that Assistant Secretary has authority and
            responsibility;
              (8) advise the heads of other agencies and programs
            of the Department concerning matters of Indian health
            with respect to which those heads have authority and
            responsibility;
              (9) coordinate the activities of the Department
            concerning matters of Indian health; and
              (10) perform such other functions as the Secretary
            may designate.
        (d) Authority [of Secretary].--
              (1) In general._The Secretary, acting through the
            [Director of the Indian Health Service] Assistant
            Secretary, shall have the authority--
                      (A) except to the extent provided for in
                    paragraph (2), to appoint and compensate
                    employees for the Service in accordance with
                    [Title 5] title 5, United States Code;
                      (B) to enter into contracts for the
                    procurement of goods and services to carry out
                    the functions of the Service; and
                      (C) to manage, expend, and obligate all funds
                    appropriated for the Service.
              (2) Personnel actions._Notwithstanding any other
            provision of law, the provisions of section [472 of
            this title] 12 of the Act of June 18, 1934 (48 Stat.
            986; 25 U.S.C. 472), shall apply to all personnel
            actions taken with respect to new positions created
            within the Service as a result of its establishment
            under subsection (a)[of this section].
        (e) References.--Any reference to the Director of the
    Indian Health Service in any other Federal law, Executive
    order, rule, regulation, or delegation of authority, or in any
    document of or relating to the Director of the Indian Health
    Service, shall be deemed to refer to the Assistant Secretary.

    [Sec. 1662. Automated management information system]

    SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYSTEM.

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

    [Sec. 1663. Authorization of appropriations]

    SEC. 603. AUTHORIZATION OF APPROPRIATIONS.

        There [are] is authorized to be appropriated such sums as
    may be necessary for each fiscal year through fiscal year
    [2000] 2017 to carry out this [subchapter] title.

                     TITLE VII--BEHAVIORAL HEALTH PROGRAMS

    SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREATMENT SERVICES.

        (a) Purposes.--The purposes of this section are as follows:
              (1) To authorize and direct the Secretary, acting
            through the Service, Indian Tribes, Tribal
            Organizations, and Urban Indian Organizations, to
            develop a comprehensive behavioral health prevention
            and treatment program which emphasizes collaboration
            among alcohol and substance abuse, social services, and
            mental health programs.
              (2) To provide information, direction, and guidance
            relating to mental illness and dysfunction and self-
            destructive behavior, including child abuse and family
            violence, to those Federal, tribal, State, and local
            agencies responsible for programs in Indian communities
            in areas of health care, education, social services,
            child and family welfare, alcohol and substance abuse,
            law enforcement, and judicial services.
              (3) To assist Indian Tribes to identify services and
            resources available to address mental illness and
            dysfunctional and self-destructive behavior.
              (4) To provide authority and opportunities for Indian
            Tribes and Tribal Organizations to develop, implement,
            and coordinate with community-based programs which
            include identification, prevention, education,
            referral, and treatment services, including through
            multidisciplinary resource teams.
              (5) To ensure that Indians, as citizens of the United
            States and of the States in which they reside, have the
            same access to behavioral health services to which all
            citizens have access.
              (6) To modify or supplement existing programs and
            authorities in the areas identified in paragraph (2).
        (b) Plans.--
              (1) Development.--The Secretary, acting through the
            Service, Indian Tribes, Tribal Organizations, and Urban
            Indian Organizations, shall encourage Indian Tribes and
            Tribal Organizations to develop tribal plans, and Urban
            Indian Organizations to develop local plans, and for
            all such groups to participate in developing areawide
            plans for Indian Behavioral Health Services. The plans
            shall include, to the extent feasible, the following
            components:
                      (A) An assessment of the scope of alcohol or
                    other substance abuse, mental illness, and
                    dysfunctional and self-destructive behavior,
                    including suicide, child abuse, and family
                    violence, among Indians, including--
                              (i) the number of Indians served who
                            are directly or indirectly affected by
                            such illness or behavior; or
                              (ii) an estimate of the financial and
                            human cost attributable to such illness
                            or behavior.
                      (B) An assessment of the existing and
                    additional resources necessary for the
                    prevention and treatment of such illness and
                    behavior, including an assessment of the
                    progress toward achieving the availability of
                    the full continuum of care described in
                    subsection (c).
                      (C) An estimate of the additional funding
                    needed by the Service, Indian Tribes, Tribal
                    Organizations, and Urban Indian Organizations
                    to meet their responsibilities under the plans.
              (2) National clearinghouse.--The Secretary, acting
            through the Service, shall coordinate with existing
            national clearinghouses and information centers to
            include at the clearinghouses and centers plans and
            reports on the outcomes of such plans developed by
            Indian Tribes, Tribal Organizations, Urban Indian
            Organizations, and Service Areas relating to behavioral
            health. The Secretary shall ensure access to these
            plans and outcomes by any Indian Tribe, Tribal
            Organization, Urban Indian Organization, or the
            Service.
              (3) Technical Assistance.--The Secretary shall
            provide technical assistance to Indian Tribes, Tribal
            Organizations, and Urban Indian Organizations in
            preparation of plans under this section and in
            developing standards of care that may be used and
            adopted locally.
        (c) Programs.--The Secretary, acting through the Service,
    Indian Tribes, and Tribal Organizations, shall provide, to the
    extent feasible and if funding is available, programs including
    the following:
              (1) Comprehensive care.--A comprehensive continuum of
            behavioral health care which provides--
                      (A) community-based prevention, intervention,
                    outpatient, and behavioral health aftercare;
                      (B) detoxification (social and medical);
                      (C) acute hospitalization;
                      (D) intensive outpatient/day treatment;
                      (E) residential treatment;
                      (F) transitional living for those needing a
                    temporary, stable living environment that is
                    supportive of treatment and recovery goals;
                      (G) emergency shelter;
                      (H) intensive case management; and
                      (I) diagnostic services.
              (2) Child care.--Behavioral health services for
            Indians from birth through age 17, including--
                      (A) preschool and school age fetal alcohol
                    disorder services, including assessment and
                    behavioral intervention;
                      (B) mental health and substance abuse
                    services (emotional, organic, alcohol, drug,
                    inhalant, and tobacco);
                      (C) identification and treatment of co-
                    occurring disorders and comorbidity;
                      (D) prevention of alcohol, drug, inhalant,
                    and tobacco use;
                      (E) early intervention, treatment, and
                    aftercare;
                      (F) promotion of healthy approaches to risk
                    and safety issues; and
                      (G) identification and treatment of neglect
                    and physical, mental, and sexual abuse.
              (3) Adult care.--Behavioral health services for
            Indians from age 18 through 55, including--
                      (A) early intervention, treatment, and
                    aftercare;
                      (B) mental health and substance abuse
                    services (emotional, alcohol, drug, inhalant,
                    and tobacco), including sex specific services;
                      (C) identification and treatment of co-
                    occurring disorders (dual diagnosis) and
                    comorbidity;
                      (D) promotion of healthy approaches for risk-
                    related behavior;
                      (E) treatment services for women at risk of
                    giving birth to a child with a fetal alcohol
                    disorder; and
                      (F) sex specific treatment for sexual assault
                    and domestic violence.
              (4) Family care.--Behavioral health services for
            families, including--
                      (A) early intervention, treatment, and
                    aftercare for affected families;
                      (B) treatment for sexual assault and domestic
                    violence; and
                      (C) promotion of healthy approaches relating
                    to parenting, domestic violence, and other
                    abuse issues.
              (5) Elder care.--Behavioral health services for
            Indians 56 years of age and older, including--
                      (A) early intervention, treatment, and
                    aftercare;
                      (B) mental health and substance abuse
                    services (emotional, alcohol, drug, inhalant,
                    and tobacco), including sex specific services;
                      (C) identification and treatment of co-
                    occurring disorders (dual diagnosis) and
                    comorbidity;
                      (D) promotion of healthy approaches to
                    managing conditions related to aging;
                      (E) sex specific treatment for sexual
                    assault, domestic violence, neglect, physical
                    and mental abuse and exploitation; and
                      (F) identification and treatment of dementias
                    regardless of cause.
        (d) Community Behavioral Health Plan.--
              (1) Establishment.--The governing body of any Indian
            Tribe, Tribal Organization, or Urban Indian
            Organization may adopt a resolution for the
            establishment of a community behavioral health plan
            providing for the identification and coordination of
            available resources and programs to identify, prevent,
            or treat substance abuse, mental illness, or
            dysfunctional and self-destructive behavior, including
            child abuse and family violence, among its members or
            its service population. This plan should include
            behavioral health services, social services, intensive
            outpatient services, and continuing aftercare.
              (2) Technical assistance.--At the request of an
            Indian Tribe, Tribal Organization, or Urban Indian
            Organization, the Bureau of Indian Affairs and the
            Service shall cooperate with and provide technical
            assistance to the Indian Tribe, Tribal Organization, or
            Urban Indian Organization in the development and
            implementation of such plan.
              (3) Funding.--The Secretary, acting through the
            Service, may make funding available to Indian Tribes
            and Tribal Organizations which adopt a resolution
            pursuant to paragraph (1) to obtain technical
            assistance for the development of a community
            behavioral health plan and to provide administrative
            support in the implementation of such plan.
        (e) Coordination for Availability of Services.--The
    Secretary, acting through the Service, Indian Tribes, Tribal
    Organizations, and Urban Indian Organizations, shall coordinate
    behavioral health planning, to the extent feasible, with other
    Federal agencies and with State agencies, to encourage
    comprehensive behavioral health services for Indians regardless
    of their place of residence.
        (f) Mental Health Care Need Assessment.--Not later than 1
    year after the date of enactment of the Indian Health Care
    Improvement Act Amendments of 2007, the Secretary, acting
    through the Service, shall make an assessment of the need for
    inpatient mental health care among Indians and the availability
    and cost of inpatient mental health facilities which can meet
    such need. In making such assessment, the Secretary shall
    consider the possible conversion of existing, underused Service
    hospital beds into psychiatric units to meet such need.

    SEC. 702. MEMORANDA OF AGREEMENT WITH THE DEPARTMENT OF THE INTERIOR.

        (a) Contents.--Not later than 12 months after the date of
    enactment of the Indian Health Care Improvement Act Amendments
    of 2007, the Secretary, acting through the Service, and the
    Secretary of the Interior shall develop and enter into a
    memoranda of agreement, or review and update any existing
    memoranda of agreement, as required by section 4205 of the
    Indian Alcohol and Substance Abuse Prevention and Treatment Act
    of 1986 (25 U.S.C. 2411) under which the Secretaries address
    the following:
              (1) The scope and nature of mental illness and
            dysfunctional and self-destructive behavior, including
            child abuse and family violence, among Indians.
              (2) The existing Federal, tribal, State, local, and
            private services, resources, and programs available to
            provide behavioral health services for Indians.
              (3) The unmet need for additional services,
            resources, and programs necessary to meet the needs
            identified pursuant to paragraph (1).
              (4)(A) The right of Indians, as citizens of the
            United States and of the States in which they reside,
            to have access to behavioral health services to which
            all citizens have access.
              (B) The right of Indians to participate in, and
            receive the benefit of, such services.
              (C) The actions necessary to protect the exercise of
            such right.
              (5) The responsibilities of the Bureau of Indian
            Affairs and the Service, including mental illness
            identification, prevention, education, referral, and
            treatment services (including services through
            multidisciplinary resource teams), at the central,
            area, and agency and Service Unit, Service Area, and
            headquarters levels to address the problems identified
            in paragraph (1).
              (6) A strategy for the comprehensive coordination of
            the behavioral health services provided by the Bureau
            of Indian Affairs and the Service to meet the problems
            identified pursuant to paragraph (1), including--
                      (A) the coordination of alcohol and substance
                    abuse programs of the Service, the Bureau of
                    Indian Affairs, and Indian Tribes and Tribal
                    Organizations (developed under the Indian
                    Alcohol and Substance Abuse Prevention and
                    Treatment Act of 1986 (25 U.S.C. 2401 et seq.))
                    with behavioral health initiatives pursuant to
                    this Act, particularly with respect to the
                    referral and treatment of dually diagnosed
                    individuals requiring behavioral health and
                    substance abuse treatment; and
                      (B) ensuring that the Bureau of Indian
                    Affairs and Service programs and services
                    (including multidisciplinary resource teams)
                    addressing child abuse and family violence are
                    coordinated with such non-Federal programs and
                    services.
              (7) Directing appropriate officials of the Bureau of
            Indian Affairs and the Service, particularly at the
            agency and Service Unit levels, to cooperate fully with
            tribal requests made pursuant to community behavioral
            health plans adopted under section 701(c) and section
            4206 of the Indian Alcohol and Substance Abuse
            Prevention and Treatment Act of 1986 (25 U.S.C. 2412).

    [Sec. 1665. Indian Health Service responsibilities]

              (8) Providing for an annual review of such agreement
            by the Secretaries which shall be provided to Congress
            and Indian Tribes and Tribal Organizations.
        [The Memorandum of Agreement]
        (b) Specific Provisions Required._The memoranda of
    agreement updated or entered into pursuant to [section 2411 of
    this title] subsection (a) shall include specific provisions
    pursuant to which the Service shall assume responsibility for--
              (1) the determination of the scope of the problem of
            alcohol and substance abuse among [Indian people]
            Indians, including the number of Indians within the
            jurisdiction of the Service who are directly or
            indirectly affected by alcohol and substance abuse and
            the financial and human cost;
              (2) an assessment of the existing and needed
            resources necessary for the prevention of alcohol and
            substance abuse and the treatment of Indians affected
            by alcohol and substance abuse; and
              (3) an estimate of the funding necessary to
            adequately support a program of prevention of alcohol
            and substance abuse and treatment of Indians affected
            by alcohol and substance abuse.
        (c) Publication.--Each memorandum of agreement entered into
    or renewed (and amendments or modifications thereto) under
    subsection (a) shall be published in the Federal Register. At
    the same time as publication in the Federal Register, the
    Secretary shall provide a copy of such memoranda, amendment, or
    modification to each Indian Tribe, Tribal Organization, and
    Urban Indian Organization.

    SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PREVENTION AND TREATMENT
                        PROGRAM.

    [Sec. 1665a. Indian Health Service program]

        (a) Establishment._
        [(a) Comprehensive prevention and treatment program]
              (1) In general.--The Secretary, acting through the
            Service, Indian Tribes, and Tribal Organizations, shall
            provide a program of comprehensive [alcohol and
            substance abuse prevention and treatment] behavioral
            health, prevention, treatment, and aftercare, which
            shall include--
                      (A) prevention, through educational
                    intervention, in Indian communities;
                      (B) acute detoxification [and treatment;],
                    psychiatric hospitalization, residential, and
                    intensive outpatient treatment;
                      (C) community-based rehabilitation[;] and
                    aftercare;
                      (D) community education and involvement,
                    including extensive training of health care,
                    educational, and community-based personnel;
                    [and]
                      (E) specialized residential treatment
                    programs for high-risk populations, including
                    pregnant and [post partum] postpartum women and
                    their children; and
                      (F) diagnostic services.
              (2) Target populations.--The target population of
            such [program] programs shall be members of Indian
            [tribes] Tribes. Efforts to train and educate key
            members of the Indian community shall also target
            employees of health, education, judicial, law
            enforcement, legal, and social service programs.
        (b) Contract [health services] Health Services.--
              (1) In general.--The Secretary, acting through the
            Service, Indian Tribes, and Tribal Organizations, may
            enter into contracts with public or private providers
            of [alcohol and substance abuse] behavioral health
            treatment services for the purpose of [assisting the
            Service in] carrying out the program required under
            subsection (a) [of this section].
              (2) Provision of assistance.--In carrying out this
            subsection, the Secretary shall provide assistance to
            Indian [tribes] Tribes and Tribal Organizations to
            develop criteria for the certification of [alcohol and
            substance abuse] behavioral health service providers
            and accreditation of service facilities which meet
            minimum standards for such services and facilities [as
            may be determined pursuant to section 2411(a)(3) of
            this title].
        [(c) Grants for model program
              [(1) The Secretary, acting through the Service shall
            make a grant to the Standing Rock Sioux Tribe to
            develop a community-based demonstration project to
            reduce drug and alcohol abuse on the Standing Rock
            Sioux Reservation and to rehabilitate Indian families
            afflicted by such abuse.
              [(2) Funds shall be used by the Tribe to--
                      [(A) develop and coordinate community-based
                    alcohol and substance abuse prevention and
                    treatment services for Indian families;
                      [(B) develop prevention and intervention
                    models for Indian families;
                      [(C) conduct community education on alcohol
                    and substance abuse; and
                      [(D) coordinate with existing Federal, State,
                    and tribal services on the reservation to
                    develop a comprehensive alcohol and substance
                    abuse program that assists in the
                    rehabilitation of Indian families that have
                    been or are afflicted by alcoholism.
              [(3) The Secretary shall submit to the President for
            inclusion in the report to be transmitted to the
            Congress under section 1671 of this title for fiscal
            year 1995 an evaluation of the demonstration project
            established under paragraph (1).]

    SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM.

        (a) In General.--Under the authority of the Act of November
    2, 1921 (25 U.S.C. 13) (commonly known as the ``Snyder Act''),
    the Secretary shall establish and maintain a mental health
    technician program within the Service which--
              (1) provides for the training of Indians as mental
            health technicians; and
              (2) employs such technicians in the provision of
            community-based mental health care that includes
            identification, prevention, education, referral, and
            treatment services.
        (b) Paraprofessional Training.--In carrying out subsection
    (a), the Secretary, acting through the Service, Indian Tribes,
    and Tribal Organizations, shall provide high-standard
    paraprofessional training in mental health care necessary to
    provide quality care to the Indian communities to be served.
    Such training shall be based upon a curriculum developed or
    approved by the Secretary which combines education in the
    theory of mental health care with supervised practical
    experience in the provision of such care.
        (c) Supervision and Evaluation of Technicians.--The
    Secretary, acting through the Service, Indian Tribes, and
    Tribal Organizations, shall supervise and evaluate the mental
    health technicians in the training program.
        (d) Traditional Health Care Practices.--The Secretary,
    acting through the Service, shall ensure that the program
    established pursuant to this subsection involves the use and
    promotion of the traditional health care practices of the
    Indian Tribes to be served.

    SEC. 705. LICENSING REQUIREMENT FOR MENTAL HEALTH CARE WORKERS.

        (a) In General.--Subject to the provisions of section 221,
    and except as provided in subsection (b), any individual
    employed as a psychologist, social worker, or marriage and
    family therapist for the purpose of providing mental health
    care services to Indians in a clinical setting under this Act
    is required to be licensed as a psychologist, social worker, or
    marriage and family therapist, respectively.
        (b) Trainees.--An individual may be employed as a trainee
    in psychology, social work, or marriage and family therapy to
    provide mental health care services described in subsection (a)
    if such individual--
              (1) works under the direct supervision of a licensed
            psychologist, social worker, or marriage and family
            therapist, respectively;
              (2) is enrolled in or has completed at least 2 years
            of course work at a post-secondary, accredited
            education program for psychology, social work, marriage
            and family therapy, or counseling; and
              (3) meets such other training, supervision, and
            quality review requirements as the Secretary may
            establish.

    [Sec. 1665b. Indian women treatment programs]

    SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS.

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

    [Sec. 1665c. Indian Health Service youth program]

    SEC. 707. INDIAN YOUTH PROGRAM.

        (a) Detoxification and [rehabilitation] Rehabilitation._The
    Secretary, acting through the Service, consistent with section
    701, shall develop and implement a program for acute
    detoxification and treatment for Indian [youth who are alcohol
    and substance abusers] youths, including behavioral health
    services. The program shall include regional treatment centers
    designed to include detoxification and rehabilitation for both
    sexes on a referral basis. [These regional] and programs
    developed and implemented by Indian Tribes or Tribal
    Organizations at the local level under the Indian Self-
    Determination and Education Assistance Act (25 U.S.C. 450 et
    seq.). Regional centers shall be integrated with the intake and
    rehabilitation programs based in the referring Indian
    community.
        (b) Alcohol and Substance Abuse Treatment [centers or
    facilities] Centers or Facilities.--
              (1) Establishment.--
                      (A) In general.--The Secretary, acting
                    through the Service, Indian Tribes, and Tribal
                    Organizations, shall construct, renovate, or,
                    as necessary, purchase, and appropriately staff
                    and operate, [a] at least 1 youth regional
                    treatment center or treatment network in each
                    area under the jurisdiction of an [area office]
                    Area Office.
                      (B) Area office in california._For the
                    purposes of this subsection, the [area offices
                    of the Service in Tucson and Phoenix, Arizona,
                    shall be considered one area office and the
                    area office] Area Office in California shall be
                    considered to be [two area offices, one] 2 Area
                    Offices, 1 office whose jurisdiction shall be
                    considered to encompass the northern area of
                    the State of California, and [one] 1 office
                    whose jurisdiction shall be considered to
                    encompass the remainder of the State of
                    California for the purpose of implementing
                    California treatment networks.
              (2) Funding._For the purpose of staffing and
            operating such centers or facilities, funding shall be
            pursuant to the Act of November 2, 1921 (25 U.S.C. 13).
              (3) Location._A youth treatment center constructed or
            purchased under this subsection shall be constructed or
            purchased at a location within the area described in
            paragraph (1) agreed upon (by appropriate tribal
            resolution) by a majority of the [tribes] Indian Tribes
            to be served by such center.
              (4) Specific provision of funds._
              (4A) [(A)] In general._Notwithstanding any other
            provision of this [subchapter] title, the Secretary
            may, from amounts authorized to be appropriated for the
            purposes of carrying out this section, make funds
            available to--
                      (i) the Tanana Chiefs Conference,
                    Incorporated, for the purpose of leasing,
                    constructing, renovating, operating[,] and
                    maintaining a residential youth treatment
                    facility in Fairbanks, Alaska; and
                      (ii) the Southeast Alaska Regional Health
                    Corporation to staff and operate a residential
                    youth treatment facility without regard to the
                    proviso set forth in section [450b(l) of this
                    title] 4(l) of the Indian Self-Determination
                    and Education Assistance Act (25 U.S.C.
                    450b(l)).
              (B) Provision of services to eligible youths._Until
            additional residential youth treatment facilities are
            established in Alaska pursuant to this section, the
            facilities specified in subparagraph (A) shall make
            every effort to provide services to all eligible Indian
            youths residing in Alaska.
              [(B) Until additional residential youth treatment
            facilities are established in Alaska pursuant to this
            section, the facilities specified in subparagraph (A)
            shall make every effort to provide services to all
            eligible Indian youth residing in such State.]
        (c) Intermediate Adolescent Behavioral Health Services.--
              (1) In general.--The Secretary, acting through the
            Service, Indian Tribes, and Tribal Organizations, may
            provide intermediate behavioral health services to
            Indian children and adolescents, including--
                      (A) pretreatment assistance;
                      (B) inpatient, outpatient, and aftercare
                    services;
                      (C) emergency care;
                      (D) suicide prevention and crisis
                    intervention; and
                      (E) prevention and treatment of mental
                    illness and dysfunctional and self-destructive
                    behavior, including child abuse and family
                    violence.
              (2) Use of funds.--Funds provided under this
            subsection may be used--
                      (A) to construct or renovate an existing
                    health facility to provide intermediate
                    behavioral health services;
                      (B) to hire behavioral health professionals;
                      (C) to staff, operate, and maintain an
                    intermediate mental health facility, group
                    home, sober housing, transitional housing or
                    similar facilities, or youth shelter where
                    intermediate behavioral health services are
                    being provided;
                      (D) to make renovations and hire appropriate
                    staff to convert existing hospital beds into
                    adolescent psychiatric units; and
                      (E) for intensive home- and community-based
                    services.
              (3) Criteria.--The Secretary, acting through the
            Service, shall, in consultation with Indian Tribes and
            Tribal Organizations, establish criteria for the review
            and approval of applications or proposals for funding
            made available pursuant to this subsection.
        [(c)] (d) Federally[owned structures]-Owned Structures.--
              (1) In general._The Secretary, [acting through the
            Service, shall,] in consultation with Indian [tribes]
            Tribes and Tribal Organizations, shall--
                      (A) identify and use, where appropriate,
                    federally-owned structures suitable [as] for
                    local residential or regional [alcohol and
                    substance abuse] behavioral health treatment
                    [centers] for Indian [youth] youths; and
                      (B) establish guidelines for determining the
                    suitability of any such federally-owned
                    structure to be used [as a] for local
                    residential or regional [alcohol and substance
                    abuse] behavioral health treatment [center] for
                    Indian [youth] youths.
        [(2)] (2) Terms and conditions for use of structure._Any
    structure described in paragraph (1) may be used under such
    terms and conditions as may be agreed upon by the Secretary and
    the agency having responsibility for the structure and any
    Indian Tribe or Tribal Organization operating the program.
        [(d)] (e) Rehabilitation and [aftercare services] Aftercare
    Services.--
              (1) In general._The Secretary, Indian Tribes, or
            Tribal Organizations, in cooperation with the Secretary
            of the Interior, shall develop and implement within
            each Service [service unit] Unit, community-based
            rehabilitation and follow-up services for Indian [youth
            who are alcohol or substance abusers which are designed
            to integrate] youths who are having significant
            behavioral health problems, and require long-term
            treatment, community reintegration, and monitoring to
            [monitor and] support the Indian [youth] youths after
            their return to their home community.
              (2) Administration._Services under paragraph (1)
            shall be [administered within each service unit]
            provided by trained staff within the community who can
            assist the Indian [youth] youths in their continuing
            development of self-image, positive problem-solving
            skills, and nonalcohol or substance abusing behaviors.
            Such staff [shall] may include alcohol and substance
            abuse counselors, mental health professionals, and
            other health professionals and paraprofessionals,
            including community health representatives.
        [(e)] (f) Inclusion of [family in youth treatment program]
    Family in Youth Treatment Program.--In providing the treatment
    and other services to Indian [youth] youths authorized by this
    section, the Secretary, acting through the Service, Indian
    Tribes, and Tribal Organizations, shall provide for the
    inclusion of family members of such [youth] youths in the
    treatment programs or other services as may be appropriate. Not
    less than 10 percent of the funds appropriated for the purposes
    of carrying out subsection [(d) of this section] (e) shall be
    used for outpatient care of adult family members related to the
    treatment of an Indian youth under that subsection.
        [(f) Multidrug abuse study (1) The Secretary shall conduct
    a study to determine the incidence and prevalence of] (g)
    Multidrug Abuse Program.--The Secretary, acting through the
    Service, Indian Tribes, Tribal Organizations, and Urban Indian
    Organizations, shall provide, consistent with section 701,
    programs and services to prevent and treat the abuse of
    multiple forms of [drugs] substances, including alcohol, drugs,
    inhalants, and tobacco, among Indian [youth] youths residing
    [on Indian] in Indian communities, on or near reservations, and
    in urban areas and [the interrelationship of such abuse with]
    provide appropriate mental health services to address the
    incidence of mental illness among such [youth] youths.
        [(2) The Secretary shall submit a report detailing the
    findings of such study, together with recommendations based on
    such findings, to the Congress no later than two years after
    October 29, 1992.]
        (h) Indian Youth Mental Health.--The Secretary, acting
    through the Service, shall collect data for the report under
    section 801 with respect to--
              (1) the number of Indian youth who are being provided
            mental health services through the Service and Tribal
            Health Programs;
              (2) a description of, and costs associated with, the
            mental health services provided for Indian youth
            through the Service and Tribal Health Programs;
              (3) the number of youth referred to the Service or
            Tribal Health Programs for mental health services;
              (4) the number of Indian youth provided residential
            treatment for mental health and behavioral problems
            through the Service and Tribal Health Programs,
            reported separately for on- and off-reservation
            facilities; and
              (5) the costs of the services described in paragraph
            (4).

    SEC. 708. INDIAN YOUTH TELEMENTAL HEALTH DEMONSTRATION PROJECT.

        (a) Purpose.--The purpose of this section is to authorize
    the Secretary to carry out a demonstration project to test the
    use of telemental health services in suicide prevention,
    intervention and treatment of Indian youth, including through--
              (1) the use of psychotherapy, psychiatric
            assessments, diagnostic interviews, therapies for
            mental health conditions predisposing to suicide, and
            alcohol and substance abuse treatment;
              (2) the provision of clinical expertise to,
            consultation services with, and medical advice and
            training for frontline health care providers working
            with Indian youth;
              (3) training and related support for community
            leaders, family members and health and education
            workers who work with Indian youth;
              (4) the development of culturally-relevant
            educational materials on suicide; and
              (5) data collection and reporting.
        (b) Definitions.--For the purpose of this section, the
    following definitions shall apply:
              (1) Demonstration project.--The term ``demonstration
            project'' means the Indian youth telemental health
            demonstration project authorized under subsection (c).
              (2) Telemental health.--The term ``telemental
            health'' means the use of electronic information and
            telecommunications technologies to support long
            distance mental health care, patient and professional-
            related education, public health, and health
            administration.
        (c) Authorization.--
              (1) In general.--The Secretary is authorized to award
            grants under the demonstration project for the
            provision of telemental health services to Indian youth
            who--
                      (A) have expressed suicidal ideas;
                      (B) have attempted suicide; or
                      (C) have mental health conditions that
                    increase or could increase the risk of suicide.
              (2) Eligibility for grants.--Such grants shall be
            awarded to Indian Tribes and Tribal Organizations that
            operate 1 or more facilities--
                      (A) located in Alaska and part of the Alaska
                    Federal Health Care Access Network;
                      (B) reporting active clinical telehealth
                    capabilities; or
                      (C) offering school-based telemental health
                    services relating to psychiatry to Indian
                    youth.
              (3) Grant period.--The Secretary shall award grants
            under this section for a period of up to 4 years.
              (4) Awarding of grants.--Not more than 5 grants shall
            be provided under paragraph (1), with priority
            consideration given to Indian Tribes and Tribal
            Organizations that--
                      (A) serve a particular community or
                    geographic area where there is a demonstrated
                    need to address Indian youth suicide;
                      (B) enter into collaborative partnerships
                    with Indian Health Service or Tribal Health
                    Programs or facilities to provide services
                    under this demonstration project;
                      (C) serve an isolated community or geographic
                    area which has limited or no access to
                    behavioral health services; or
                      (D) operate a detention facility at which
                    Indian youth are detained.
        (d) Use of Funds.--
              (1) In general.--An Indian Tribe or Tribal
            Organization shall use a grant received under
            subsection (c) for the following purposes:
                      (A) To provide telemental health services to
                    Indian youth, including the provision of--
                              (i) psychotherapy;
                              (ii) psychiatric assessments and
                            diagnostic interviews, therapies for
                            mental health conditions predisposing
                            to suicide, and treatment; and
                              (iii) alcohol and substance abuse
                            treatment.
                      (B) To provide clinician-interactive medical
                    advice, guidance and training, assistance in
                    diagnosis and interpretation, crisis counseling
                    and intervention, and related assistance to
                    Service, tribal, or urban clinicians and health
                    services providers working with youth being
                    served under this demonstration project.
                      (C) To assist, educate and train community
                    leaders, health education professionals and
                    paraprofessionals, tribal outreach workers, and
                    family members who work with the youth
                    receiving telemental health services under this
                    demonstration project, including with
                    identification of suicidal tendencies, crisis
                    intervention and suicide prevention, emergency
                    skill development, and building and expanding
                    networks among these individuals and with State
                    and local health services providers.
                      (D) To develop and distribute culturally
                    appropriate community educational materials
                    on--
                              (i) suicide prevention;
                              (ii) suicide education;
                              (iii) suicide screening;
                              (iv) suicide intervention; and
                              (v) ways to mobilize communities with
                            respect to the identification of risk
                            factors for suicide.
                      (E) For data collection and reporting related
                    to Indian youth suicide prevention efforts.
              (2) Traditional health care practices.--In carrying
            out the purposes described in paragraph (1), an Indian
            Tribe or Tribal Organization may use and promote the
            traditional health care practices of the Indian Tribes
            of the youth to be served.
        (e) Applications.--To be eligible to receive a grant under
    subsection (c), an Indian Tribe or Tribal Organization shall
    prepare and submit to the Secretary an application, at such
    time, in such manner, and containing such information as the
    Secretary may require, including--
              (1) a description of the project that the Indian
            Tribe or Tribal Organization will carry out using the
            funds provided under the grant;
              (2) a description of the manner in which the project
            funded under the grant would--
                      (A) meet the telemental health care needs of
                    the Indian youth population to be served by the
                    project; or
                      (B) improve the access of the Indian youth
                    population to be served to suicide prevention
                    and treatment services;
              (3) evidence of support for the project from the
            local community to be served by the project;
              (4) a description of how the families and leadership
            of the communities or populations to be served by the
            project would be involved in the development and
            ongoing operations of the project;
              (5) a plan to involve the tribal community of the
            youth who are provided services by the project in
            planning and evaluating the mental health care and
            suicide prevention efforts provided, in order to ensure
            the integration of community, clinical, environmental,
            and cultural components of the treatment; and
              (6) a plan for sustaining the project after Federal
            assistance for the demonstration project has
            terminated.
        (f) Collaboration; Reporting to National Clearinghouse--
              (1) Collaboration.--The Secretary, acting through the
            Service, shall encourage Indian Tribes and Tribal
            Organizations receiving grants under this section to
            collaborate to enable comparisons about best practices
            across projects.
              (2) Reporting to national clearinghouse.--The
            Secretary, acting through the Service, shall also
            encourage Indian Tribes and Tribal Organizations
            receiving grants under this section to submit relevant,
            declassified project information to the national
            clearinghouse authorized under section 701(b)(2) in
            order to better facilitate program performance and
            improve suicide prevention, intervention, and treatment
            services.
        (g) Annual Report.--Each grant recipient shall submit to
    the Secretary an annual report that--
              (1) describes the number of telemental health
            services provided; and
              (2) includes any other information that the Secretary
            may require.
        (h) Report to Congress.--Not later than 270 days after the
    termination of the demonstration project, the Secretary shall
    submit to the Committee on Indian Affairs of the Senate and the
    Committee on Natural Resources and Committee on Energy and
    Commerce of the House of Representatives a final report, based
    on the annual reports provided by grant recipients under
    subsection (h), that--
              (1) describes the results of the projects funded by
            grants awarded under this section, including any data
            available which indicates the number of attempted
            suicides;
              (2) evaluates the impact of the telemental health
            services funded by the grants in reducing the number of
            completed suicides among Indian youth;
              (3) evaluates whether the demonstration project
            should be--
                      (A) expanded to provide more than 5 grants;
                    and
                      (B) designated a permanent program; and
              (4) evaluates the benefits of expanding the
            demonstration project to include Urban Indian
            Organizations.
        (i) Authorization of Appropriations.--There is authorized
    to be appropriated to carry out this section $1,500,000 for
    each of fiscal years 2008 through 2011.

    SEC. 709. INPATIENT AND COMMUNITY-BASED MENTAL HEALTH FACILITIES
                        DESIGN, CONSTRUCTION, AND STAFFING.

        Not later than 1 year after the date of enactment of the
    Indian Health Care Improvement Act Amendments of 2007, the
    Secretary, acting through the Service, Indian Tribes, and
    Tribal Organizations, may provide, in each area of the Service,
    not less than 1 inpatient mental health care facility, or the
    equivalent, for Indians with behavioral health problems. For
    the purposes of this subsection, California shall be considered
    to be 2 Area Offices, 1 office whose location shall be
    considered to encompass the northern area of the State of
    California and 1 office whose jurisdiction shall be considered
    to encompass the remainder of the State of California. The
    Secretary shall consider the possible conversion of existing,
    underused Service hospital beds into psychiatric units to meet
    such need.

    [Sec. 1665d. Training and community education]

    SEC. 710. TRAINING AND COMMUNITY EDUCATION.

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

    SEC. 711. BEHAVIORAL HEALTH PROGRAM.

        (a) Innovative Programs.--The Secretary, acting through the
    Service, Indian Tribes, and Tribal Organizations, consistent
    with section 701, may plan, develop, implement, and carry out
    programs to deliver innovative community-based behavioral
    health services to Indians.
        (b) Awards; Criteria.--The Secretary may award a grant for
    a project under subsection (a) to an Indian Tribe or Tribal
    Organization and may consider the following criteria:
              (1) The project will address significant unmet
            behavioral health needs among Indians.
              (2) The project will serve a significant number of
            Indians.
              (3) The project has the potential to deliver services
            in an efficient and effective manner.
              (4) The Indian Tribe or Tribal Organization has the
            administrative and financial capability to administer
            the project.

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

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

    [Sec. 1665f. Reports]

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

    SEC. 712. FETAL ALCOHOL DISORDER PROGRAMS.

    [Sec. 1665g. Fetal alcohol syndrome and fetal alcohol effect grants]

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

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

    SEC. 713. CHILD SEXUAL ABUSE AND PREVENTION TREATMENT PROGRAMS.

        (a) Establishment.--The Secretary, acting through the
    Service, [shall continue to make grants, through fiscal year
    1995, to the 8 Northern Indian Pueblos Council, San Juan
    Pueblo, New Mexico, for the purpose of providing substance
    abuse treatment services to Indians in need of such services.]
    and the Secretary of the Interior, Indian Tribes, and Tribal
    Organizations, shall establish, consistent with section 701, in
    every Service Area, programs involving treatment for--
              (1) victims of sexual abuse who are Indian children
            or children in an Indian household; and
              (2) perpetrators of child sexual abuse who are Indian
            or members of an Indian household.
        (b) Use of Funds.--Funding provided pursuant to this
    section shall be used for the following:
              (1) To develop and provide community education and
            prevention programs related to sexual abuse of Indian
            children or children in an Indian household.
              (2) To identify and provide behavioral health
            treatment to victims of sexual abuse who are Indian
            children or children in an Indian household, and to
            their family members who are affected by sexual abuse.
              (3) To develop prevention and intervention models
            which incorporate traditional health care practices,
            cultural values, and community involvement.
              (4) To develop and implement culturally sensitive
            assessment and diagnostic tools for use in Indian
            communities and Urban Centers.
              (5) To identify and provide behavioral health
            treatment to Indian perpetrators and perpetrators who
            are members of an Indian household--
                      (A) making efforts to begin offender and
                    behavioral health treatment while the
                    perpetrator is incarcerated or at the earliest
                    possible date if the perpetrator is not
                    incarcerated; and
                      (B) providing treatment after the perpetrator
                    is released, until it is determined that the
                    perpetrator is not a threat to children.
        (c) Coordination.--The programs established under
    subsection (a) shall be carried out in coordination with
    programs and services authorized under the Indian Child
    Protection and Family Violence Prevention Act (25 U.S.C. 3201
    et seq.).

    SEC. 714. BEHAVIORAL HEALTH RESEARCH.

        The Secretary, in consultation with appropriate Federal
    agencies, shall make grants to, or enter into contracts with,
    Indian Tribes, Tribal Organizations, and Urban Indian
    Organizations or enter into contracts with, or make grants to
    appropriate institutions for, the conduct of research on the
    incidence and prevalence of behavioral health problems among
    Indians served by the Service, Indian Tribes, or Tribal
    Organizations and among Indians in urban areas. Research
    priorities under this section shall include--
              (1) the multifactorial causes of Indian youth
            suicide, including--
                      (A) protective and risk factors and
                    scientific data that identifies those factors;
                    and
                      (B) the effects of loss of cultural identity
                    and the development of scientific data on those
                    effects;
              (2) the interrelationship and interdependence of
            behavioral health problems with alcoholism and other
            substance abuse, suicide, homicides, other injuries,
            and the incidence of family violence; and

    [Sec. 1665i. Thunder Child Treatment Center]

              (3) the development of models of prevention
            techniques.
        [(a) The Secretary, acting through the Service, shall make
    a grant to the Intertribal Addictions Recovery Organization,
    Inc. (commonly known as the Thunder Child Treatment Center) at
    Sheridan, Wyoming, for the completion of construction of a
    multiple approach substance abuse treatment center which
    specializes in the treatment of alcohol and drug abuse of
    Indians.
        [(b) For the purposes of carrying out subsection (a) of
    this section, there are authorized to be appropriated
    $2,000,000 for fiscal years 1993 and 1994. No funding shall be
    available for staffing or operation of this facility. None of
    the funding appropriated to carry out subsection (a) of this
    section shall be used for administrative purposes.]
        The effect of the interrelationships and interdependencies
    referred to in paragraph (2) on children, and the development
    of prevention techniques under paragraph (3) applicable to
    children, shall be emphasized.

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

    SEC. 715. DEFINITIONS.

        [(a) Contracts and grants
        [The Secretary, acting through the Service, may enter into
    contracts with, or make grants to, accredited tribally
    controlled community colleges, tribally controlled
    postsecondary vocational institutions, and eligible community
    colleges to establish demonstration projects to develop
    educational curricula for substance abuse counseling.
        [(b) Use of funds
        [Funds provided under this section shall be used only for
    developing and providing educational curricula for substance
    abuse counseling (including paying salaries for instructors).
    Such curricula may be provided through satellite campus
    programs.
        [(c) Effective period of contract or grant; renewal
        [A contract entered into or a grant provided under this
    section shall be for a period of one year. Such contract or
    grant may be renewed for an additional one year period upon the
    approval of the Secretary.
        [(d) Criteria for review and approval of applications
        [Not later than 180 days after October 29, 1992, the
    Secretary, after consultation with Indian tribes and
    administrators of accredited tribally controlled community
    colleges, tribally controlled postsecondary vocational
    institutions, and eligible community colleges, shall develop
    and issue criteria for the review and approval of applications
    for funding (including applications for renewals of funding)
    under this section. Such criteria shall ensure that
    demonstration projects established under this section promote
    the development of the capacity of such entities to educate
    substance abuse counselors.
        [(e) Assistance to recipients
        [The Secretary shall provide such technical and other
    assistance as may be necessary to enable grant recipients to
    comply with the provisions of this section.
        [(f) Report
        [The Secretary shall submit to the President, for inclusion
    in the report which is required to be submitted under section
    1671 of this title for fiscal year 1999, a report on the
    findings and conclusions derived from the demonstration
    projects conducted under this section.
        [(g) Definitions]
        For the [purposes] purpose of this [section] title, the
    following definitions shall apply:
              [(1) The term ``educational curriculum'' means one or
            more of the following:
                      [(A) Classroom education.
                      [(B) Clinical work experience.
                      [(C) Continuing education workshops.
              [(2) The term ``eligible community college'' means an
            accredited community college that--
                      [(i) is located on or near an Indian
                    reservation;
                      [(ii) has entered into a cooperative
                    agreement with the governing body of such
                    Indian reservation to carry out a demonstration
                    project under this section; and
                      [(iii) has a student enrollment of not less
                    than 10 percent Indian.
              [(3) The term ``tribally controlled community
            college'' has the meaning given such term in section
            1801(a)(4) of this title.
              [(4) The term ``tribally controlled postsecondary
            vocational institution'' has the meaning given such
            term in section 2397h(2) of Title 20.
        [(h) Authorization of appropriations
        [There are authorized to be appropriated for each of fiscal
    years 1996 through 2000, such sums as may be necessary to carry
    out the purposes of this section. Such sums shall remain
    available until expended.]
              (1) Assessment.--The term ``assessment'' means the
            systematic collection, analysis, and dissemination of
            information on health status, health needs, and health
            problems.
              (2) Alcohol-related neurodevelopmental disorders or
            arnd.--The term ``alcohol-related neurodevelopmental
            disorders'' or ``ARND'' means, with a history of
            maternal alcohol consumption during pregnancy, central
            nervous system involvement such as developmental delay,
            intellectual deficit, or neurologic abnormalities.
            Behaviorally, there can be problems with irritability,
            and failure to thrive as infants. As children become
            older there will likely be hyperactivity, attention
            deficit, language dysfunction, and perceptual and
            judgment problems.
              (3) Behavioral health aftercare.--The term
            ``behavioral health aftercare'' includes those
            activities and resources used to support recovery
            following inpatient, residential, intensive substance
            abuse, or mental health outpatient or outpatient
            treatment. The purpose is to help prevent or deal with
            relapse by ensuring that by the time a client or
            patient is discharged from a level of care, such as
            outpatient treatment, an aftercare plan has been
            developed with the client. An aftercare plan may use
            such resources as a community-based therapeutic group,
            transitional living facilities, a 12-step sponsor, a
            local 12-step or other related support group, and other
            community-based providers.
              (4) Dual diagnosis.--The term ``dual diagnosis''
            means coexisting substance abuse and mental illness
            conditions or diagnosis. Such clients are sometimes
            referred to as mentally ill chemical abusers (MICAs).
              (5) Fetal alcohol disorders.--The term ``fetal
            alcohol disorders'' means fetal alcohol syndrome,
            partial fetal alcohol syndrome and alcohol related
            neurodevelopmental disorder (ARND).
              (6) Fetal alcohol syndrome or fas.--The term ``fetal
            alcohol syndrome'' or ``FAS'' means a syndrome in
            which, with a history of maternal alcohol consumption
            during pregnancy, the following criteria are met:
                      (A) Central nervous system involvement such
                    as developmental delay, intellectual deficit,
                    microencephaly, or neurologic abnormalities.
                      (B) Craniofacial abnormalities with at least
                    2 of the following: microophthalmia, short
                    palpebral fissures, poorly developed philtrum,
                    thin upper lip, flat nasal bridge, and short
                    upturned nose.
                      (C) Prenatal or postnatal growth delay.

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

              (7) Partial fas.--The term ``partial FAS'' means,
            with a history of maternal alcohol consumption during
            pregnancy, having most of the criteria of FAS, though
            not meeting a minimum of at least 2 of the following:
            microophthalmia, short palpebral fissures, poorly
            developed philtrum, thin upper lip, flat nasal bridge,
            and short upturned nose.
        [(a) Regional center
        [The Secretary, acting through the Service, shall establish
    a regional youth alcohol and substance abuse prevention and
    treatment center in Sacaton, Arizona, on the Gila River Indian
    Reservation. The center shall be established within facilities
    leased, with the consent of the Gila River Indian Community, by
    the Service from such Community.
        [(b) Name of regional center
        [The center established pursuant to this section shall be
    known as the ``Regional Youth Alcohol and Substance Abuse
    Prevention and Treatment Center''.
        [(c) Unit of regional center
        [The Secretary, acting through the Service, shall
    establish, as a unit of the regional center, a youth alcohol
    and substance abuse prevention and treatment facility in
    Fallon, Nevada.]
              (8) Rehabilitation.--The term ``rehabilitation''
            means to restore the ability or capacity to engage in
            usual and customary life activities through education
            and therapy.

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

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

    SEC. 716. AUTHORIZATION OF APPROPRIATIONS.

    [Sec. 1665m. Authorization of appropriations]

        There is authorized to be appropriated such sums as may be
    necessary for each fiscal year through fiscal year 2017 to
    carry out the provisions of this title.
        [Except as provided in sections 1665b, 1665e, 1665g, 1665i,
    and 1665j of this title, there are authorized to be
    appropriated such sums as may be necessary for each fiscal year
    through fiscal year 2000 to carry out the provisions of this
    subchapter.]

                           TITLE VIII--MISCELLANEOUS

    [Sec. 1671. Reports]

    SEC. 801. REPORTS.

        [The President shall, at the time the budget is submitted
    under section 1105 of Title 31, United States Code, for each
    fiscal year transmit to the] For each fiscal year following the
    date of enactment of the Indian Health Care Improvement Act
    Amendments of 2007, the Secretary shall transmit to Congress a
    report containing--the following:
              (1) [a] A report on the progress made in meeting the
            objectives of this [chapter] Act, including a review of
            programs established or assisted pursuant to this
            [chapter] Act and [an assessment] assessments and
            recommendations of additional programs or additional
            assistance necessary to, at a minimum, provide health
            services to Indians[,] and ensure a health status for
            Indians, which are at a parity with the health services
            available to and the health status of[,] the general
            population[;].
              (2) [a] A report on whether, and to what extent, new
            national health care programs, benefits, initiatives,
            or financing systems have had an impact on the purposes
            of this [chapter] Act and any steps that the Secretary
            may have taken to consult with Indian [tribes] Tribes,
            Tribal Organizations, and Urban Indian Organizations to
            address such impact[; (3)] , including a report on
            proposed changes in allocation of funding pursuant to
            section 808.
              (3) A report on the use of health services by
            Indians--
                      (A) on a national and area or other relevant
                    geographical basis;
                      (B) by gender and age;
                      (C) by source of payment and type of service;
                    [and]
                      (D) comparing such rates of use with rates of
                    use among comparable non-Indian populations[.]
                    ; and
                      (E) provided under contracts.
              (4) A report of contractors to the Secretary on
            Health Care Educational Loan Repayments every 6 months
            required by section 110.
              (5) A general audit report of the Secretary on the
            Health Care Educational Loan Repayment Program as
            required by section 110(n).
              (6) A report of the findings and conclusions of
            demonstration programs on development of educational
            curricula for substance abuse counseling as required in
            section 125(f).
              [(4)] (7) [a] A separate statement which specifies
            the amount of funds requested to carry out the
            provisions of section [1621 of this title;] 201.
              [(5) a separate statement of the total amount
            obligated or expended in the most recently completed
            fiscal year to achieve each of the objectives described
            in section 1680d of this title, relating to infant and
            maternal mortality and fetal alcohol syndrome;
              [(6) the reports required by sections 1602(d),
            1616a(n), 1621b(b), 1621h(j), 1631(c), 1632(g),
            1634(a)(3), 1643, 1665g(e), 1680g(a), and 1680l(f) of
            this title;
              [(7) for fiscal year 1995, the report required by
            sections 1665a(c)(3) and 1665l(b) of this title;
              [(8) for fiscal year 1997, the interim report
            required by section 1637(h)(1) of this title; and
              [(9) for fiscal year 1999, the reports required by
            sections 1637(h)(2), 1660b(b), and 1680k(g) of this
            title.]
              (8) A report of the evaluations of health promotion
            and disease prevention as required in section 203(c).
              (9) A biennial report to Congress on infectious
            diseases as required by section 212.
             (10) A report on environmental and nuclear health
            hazards as required by section 215.
             (11) An annual report on the status of all health care
            facilities needs as required by section 301(c)(2)(B)
            and 301(d).
             (12) Reports on safe water and sanitary waste disposal
            facilities as required by section 302(h).
             (13) An annual report on the expenditure of non-
            Service funds for renovation as required by sections
            304(b)(2).
             (14) A report identifying the backlog of maintenance
            and repair required at Service and tribal facilities
            required by section 313(a).
             (15) A report providing an accounting of reimbursement
            funds made available to the Secretary under titles
            XVIII, XIX, and XXI of the Social Security Act.
             (16) A report on any arrangements for the sharing of
            medical facilities or services, as authorized by
            section 406.
             (17) A report on evaluation and renewal of Urban
            Indian programs under section 505.
             (18) A report on the evaluation of programs as
            required by section 513(d).
             (19) A report on alcohol and substance abuse as
            required by section 701(f).
             (20) A report on Indian youth mental health services
            as required by section 707(h).
             (21) A report on the reallocation of base resources if
            required by section 808.

    SEC. 802. REGULATIONS.

        (a) Deadlines.--
             (1) Procedures.--Not later than 90 days after the date
            of enactment of the Indian Health Care Improvement Act
            Amendments of 2007, the Secretary shall initiate
            procedures under subchapter III of chapter 5 of title
            5, United States Code, to negotiate and promulgate such
            regulations or amendments thereto that are necessary to
            carry out titles II (except section 202) and VII, the
            sections of title III for which negotiated rulemaking
            is specifically required, and section 807. Unless
            otherwise required, the Secretary may promulgate
            regulations to carry out titles I, III, IV, and V, and
            section 202, using the procedures required by chapter V
            of title 5, United States Code (commonly known as the
            ``Administrative Procedure Act'').
             (2) Proposed regulations.--Proposed regulations to
            implement this Act shall be published in the Federal
            Register by the Secretary no later than 2 years after
            the date of enactment of the Indian Health Care
            Improvement Act Amendments of 2007 and shall have no
            less than a 120-day comment period.
             (3) Final regulations.--The Secretary shall publish in
            the Federal Register final regulations to implement
            this Act by not later than 3 years after the date of
            enactment of the Indian Health Care Improvement Act
            Amendments of 2007.
        (b) Committee.--A negotiated rulemaking committee
    established pursuant to section 565 of title 5, United States
    Code, to carry out this section shall have as its members only
    representatives of the Federal Government and representatives
    of Indian Tribes, and Tribal Organizations, a majority of whom
    shall be nominated by and be representatives of Indian Tribes
    and Tribal Organizations from each Service Area.
        (c) Adaptation of Procedures.--The Secretary shall adapt
    the negotiated rulemaking procedures to the unique context of
    self-governance and the government-to-government relationship
    between the United States and Indian Tribes.

    [Sec. 1672.]

        (d) Lack of Regulations.--The lack of promulgated
    regulations shall not limit the effect of this Act.
        [Prior to any revision of or amendment to rules or
    regulations promulgated pursuant to this chapter, the Secretary
    shall consult with Indian tribes and appropriate national or
    regional Indian organizations and shall publish any proposed
    revision or amendment in the Federal Register not less than
    sixty days prior to the effective date of such revision or
    amendment in order to provide adequate notice to, and receive
    comments from, other interested parties.]
        (e) Inconsistent Regulations.--The provisions of this Act
    shall supersede any conflicting provisions of law in effect on
    the day before the date of enactment of the Indian Health Care
    Improvement Act Amendments of 2007, and the Secretary is
    authorized to repeal any regulation inconsistent with the
    provisions of this Act.

    [Sec. 1674. Leases with Indian tribes]

    SEC. 803. PLAN OF IMPLEMENTATION.

        [(a) Notwithstanding any other provision of law, the
    Secretary is authorized, in carrying out the purposes of this
    chapter, to enter into leases with Indian tribes for periods
    not in excess of twenty years. Property leased by the Secretary
    from an Indian tribe may be reconstructed or renovated by the
    Secretary pursuant to an agreement with such Indian tribe.
        [(b) The Secretary may enter into leases, contracts, and
    other legal agreements with Indian tribes or tribal
    organizations which hold--
             [(1) title to;
             [(2) a leasehold interest in; or
             [(3) a beneficial interest in (where title is held by
            the United States in trust for the benefit of a
            tribe);]
    [facilities used for the administration and delivery of health
    services by the Service or by programs operated by Indian
    tribes or tribal organizations to compensate such Indian tribes
    or tribal organizations for costs associated with the use of
    such facilities for such purposes. Such costs include rent,
    depreciation based on the useful life of the building,
    principal and interest paid or accrued, operation and
    maintenance expenses, and other expenses determined by
    regulation to be allowable.]
        Not later than 9 months after the date of enactment of the
    Indian Health Care Improvement Act Amendments of 2007, the
    Secretary, in consultation with Indian Tribes, Tribal
    Organizations, and Urban Indian Organizations, shall submit to
    Congress a plan explaining the manner and schedule, by title
    and section, by which the Secretary will implement the
    provisions of this Act. This consultation may be conducted
    jointly with the annual budget consultation pursuant to the
    Indian Self-Determination and Education Assistance Act (25
    U.S.C. 450 et seq.).

    [Sec. 1675. Availability of funds]

    SEC. 804. AVAILABILITY OF FUNDS.

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

    [Sec. 1676. Limitation on use of funds appropriated to the Indian
                        Health Service]

    SEC. 805. LIMITATION ON USE OF FUNDS APPROPRIATED TO INDIAN HEALTH
                        SERVICE.

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

    [Sec. 1677. Nuclear resource development health hazards]

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

    [1678. Arizona as a contract health service delivery area

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

    SEC. 806. ELIGIBILITY OF CALIFORNIA INDIANS.

    [Sec. 1679. Eligibility of]

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

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

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

    [Sec. 1680a. Contract health facilities

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

    [Sec. 1680b. National Health Service Corps

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

    [Sec. 1680c. Health services for ineligible persons

        [(a) Individuals not otherwise eligible
              [(1) Any individual who--]
        [(A] (b) Clarification.--Nothing in this section may be
    construed as expanding the eligibility of California Indians
    for health services provided by the Service beyond the scope of
    eligibility for such health services that applied on May 1,
    1986.

    SEC. 807. HEALTH SERVICES FOR INELIGIBLE PERSONS.

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

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

    SEC. 808. REALLOCATION OF BASE RESOURCES.

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

    [Sec. 1680e. Contract health services for the Trenton service area

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

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

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

    [Sec. 1680g. Reallocation of base resources

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

    SEC. 809. RESULTS OF DEMONSTRATION PROJECTS.

        The Secretary shall provide for the dissemination to Indian
    Tribes, Tribal Organizations, and Urban Indian Organizations of
    the findings and results of demonstration projects conducted
    under this Act.

    SEC. 810. PROVISION OF SERVICES IN MONTANA.

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

    SEC. 811. MORATORIUM.

        During the period of the moratorium imposed on
    implementation of the final rule published in the Federal
    Register on September 16, 1987, by the Department of Health and
    Human Services, relating to eligibility for the health care
    services of the Indian Health Service, the Indian Health
    Service shall provide services pursuant to the criteria for
    eligibility for such services that were in effect on September
    15, 1987, subject to the provisions of sections 806 and 807,
    until the Service has submitted to the Committees on
    Appropriations of the Senate and the House of Representatives a
    budget request reflecting the increased costs associated with
    the proposed final rule, and the request has been included in
    an appropriations Act and enacted into law.

    SEC. 812. TRIBAL EMPLOYMENT.

        For purposes of section 2(2) of the Act of July 5, 1935 (49
    Stat. 450, chapter 372), an Indian Tribe or Tribal Organization
    carrying out a contract or compact pursuant to the Indian Self-
    Determination and Education Assistance Act (25 U.S.C. 450 et
    seq.) shall not be considered an ``employer''.

    SEC. 813. SEVERABILITY PROVISIONS.

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

    SEC. 814. ESTABLISHMENT OF NATIONAL BIPARTISAN COMMISSION ON INDIAN
                        HEALTH CARE.

        (a) Establishment.--There is established the National
    Bipartisan Indian Health Care Commission (the ``Commission'').
        (b) Duties of Commission.--The duties of the Commission are
    the following:
              (1) To establish a study committee composed of those
            members of the Commission appointed by the Director of
            the Service and at least 4 members of Congress from
            among the members of the Commission, the duties of
            which shall be the following:
                      (A) To the extent necessary to carry out its
                    duties, collect and compile data necessary to
                    understand the extent of Indian needs with
                    regard to the provision of health services,
                    regardless of the location of Indians,
                    including holding hearings and soliciting the
                    views of Indians, Indian Tribes, Tribal
                    Organizations, and Urban Indian Organizations,
                    which may include authorizing and making funds
                    available for feasibility studies of various
                    models for providing and funding health
                    services for all Indian beneficiaries,
                    including those who live outside of a
                    reservation, temporarily or permanently.
                      (B) To make legislative recommendations to
                    the Commission regarding the delivery of
                    Federal health care services to Indians. Such
                    recommendations shall include those related to
                    issues of eligibility, benefits, the range of
                    service providers, the cost of such services,
                    financing such services, and the optimal manner
                    in which to provide such services.
                      (C) To determine the effect of the enactment
                    of such recommendations on (i) the existing
                    system of delivery of health services for
                    Indians, and (ii) the sovereign status of
                    Indian Tribes.
                      (D) Not later than 12 months after the
                    appointment of all members of the Commission,
                    to submit a written report of its findings and
                    recommendations to the full Commission. The
                    report shall include a statement of the
                    minority and majority position of the Committee
                    and shall be disseminated, at a minimum, to
                    every Indian Tribe, Tribal Organization, and
                    Urban Indian Organization for comment to the
                    Commission.
                      (E) To report regularly to the full
                    Commission regarding the findings and
                    recommendations developed by the study
                    committee in the course of carrying out its
                    duties under this section.
              (2) To review and analyze the recommendations of the
            report of the study committee.
              (3) To make legislative recommendations to Congress
            regarding the delivery of Federal health care services
            to Indians. Such recommendations shall include those
            related to issues of eligibility, benefits, the range
            of service providers, the cost of such services,
            financing such services, and the optimal manner in
            which to provide such services.
              (4) Not later than 18 months following the date of
            appointment of all members of the Commission, submit a
            written report to Congress regarding the delivery of
            Federal health care services to Indians. Such
            recommendations shall include those related to issues
            of eligibility, benefits, the range of service
            providers, the cost of such services, financing such
            services, and the optimal manner in which to provide
            such services.
          (c) Members.--
              (1) Appointment.--The Commission shall be composed of
            25 members, appointed as follows:
                      (A) Ten members of Congress, including 3 from
                    the House of Representatives and 2 from the
                    Senate, appointed by their respective majority
                    leaders, and 3 from the House of
                    Representatives and 2 from the Senate,
                    appointed by their respective minority leaders,
                    and who shall be members of the standing
                    committees of Congress that consider
                    legislation affecting health care to Indians.
                      (B) Twelve persons chosen by the
                    congressional members of the Commission, 1 from
                    each Service Area as currently designated by
                    the Director of the Service to be chosen from
                    among 3 nominees from each Service Area put
                    forward by the Indian Tribes within the area,
                    with due regard being given to the experience
                    and expertise of the nominees in the provision
                    of health care to Indians and to a reasonable
                    representation on the commission of members who
                    are familiar with various health care delivery
                    modes and who represent Indian Tribes of
                    various size populations.
                      (C) Three persons appointed by the Director
                    who are knowledgeable about the provision of
                    health care to Indians, at least 1 of whom
                    shall be appointed from among 3 nominees put
                    forward by those programs whose funds are
                    provided in whole or in part by the Service
                    primarily or exclusively for the benefit of
                    Urban Indians.
                      (D) All those persons chosen by the
                    congressional members of the Commission and by
                    the Director shall be members of federally
                    recognized Indian Tribes.
              (2) Chair; vice chair.--The Chair and Vice Chair of
            the Commission shall be selected by the congressional
            members of the Commission.
              (3) Terms.--The terms of members of the Commission
            shall be for the life of the Commission.
              (4) Deadline for appointments.--Congressional members
            of the Commission shall be appointed not later than 180
            days after the date of enactment of the Indian Health
            Care Improvement Act Amendments of 2007, and the
            remaining members of the Commission shall be appointed
            not later than 60 days following the appointment of the
            congressional members.
              (5) Vacancy.--A vacancy in the Commission shall be
            filled in the manner in which the original appointment
            was made.
          (d) Compensation.--
              (1) Congressional members.--Each congressional member
            of the Commission shall receive no additional pay,
            allowances, or benefits by reason of their service on
            the Commission and shall receive travel expenses and
            per diem in lieu of subsistence in accordance with
            sections 5702 and 5703 of title 5, United States Code.
              (2) Other members.--Remaining members of the
            Commission, while serving on the business of the
            Commission (including travel time), shall be entitled
            to receive compensation at the per diem equivalent of
            the rate provided for level IV of the Executive
            Schedule under section 5315 of title 5, United States
            Code, and while so serving away from home and the
            member's regular place of business, a member may be
            allowed travel expenses, as authorized by the Chairman
            of the Commission. For purpose of pay (other than pay
            of members of the Commission) and employment benefits,
            rights, and privileges, all personnel of the Commission
            shall be treated as if they were employees of the
            United States Senate.
          (e) Meetings.--The Commission shall meet at the call of
    the Chair.
          (f) Quorum.--A quorum of the Commission shall consist of
    not less than 15 members, provided that no less than 6 of the
    members of Congress who are Commission members are present and
    no less than 9 of the members who are Indians are present.
          (g) Executive Director; Staff; Facilities.--
              (1) Appointment; pay.--The Commission shall appoint
            an executive director of the Commission. The executive
            director shall be paid the rate of basic pay for level
            V of the Executive Schedule.
              (2) Staff appointment.--With the approval of the
            Commission, the executive director may appoint such
            personnel as the executive director deems appropriate.
              (3) Staff pay.--The staff of the Commission shall be
            appointed without regard to the provisions of title 5,
            United States Code, governing appointments in the
            competitive service, and shall be paid without regard
            to the provisions of chapter 51 and subchapter III of
            chapter 53 of such title (relating to classification
            and General Schedule pay rates).
              (4) Temporary services.--With the approval of the
            Commission, the executive director may procure
            temporary and intermittent services under section
            3109(b) of title 5, United States Code.
              (5) Facilities.--The Administrator of General
            Services shall locate suitable office space for the
            operation of the Commission. The facilities shall serve
            as the headquarters of the Commission and shall include
            all necessary equipment and incidentals required for
            the proper functioning of the Commission.
          (h) Hearings.--
              (1) For the purpose of carrying out its duties, the
            Commission may hold such hearings and undertake such
            other activities as the Commission determines to be
            necessary to carry out its duties, provided that at
            least 6 regional hearings are held in different areas
            of the United States in which large numbers of Indians
            are present. Such hearings are to be held to solicit
            the views of Indians regarding the delivery of health
            care services to them. To constitute a hearing under
            this subsection, at least 5 members of the Commission,
            including at least 1 member of Congress, must be
            present. Hearings held by the study committee
            established in this section may count toward the number
            of regional hearings required by this subsection.
              (2) Upon request of the Commission, the Comptroller
            General shall conduct such studies or investigations as
            the Commission determines to be necessary to carry out
            its duties.
              (3)(A) The Director of the Congressional Budget
            Office or the Chief Actuary of the Centers for Medicare
            & Medicaid Services, or both, shall provide to the
            Commission, upon the request of the Commission, such
            cost estimates as the Commission determines to be
            necessary to carry out its duties.
              (B) The Commission shall reimburse the Director of
            the Congressional Budget Office for expenses relating
            to the employment in the office of that Director of
            such additional staff as may be necessary for the
            Director to comply with requests by the Commission
            under subparagraph (A).
              (4) Upon the request of the Commission, the head of
            any Federal agency is authorized to detail, without
            reimbursement, any of the personnel of such agency to
            the Commission to assist the Commission in carrying out
            its duties. Any such detail shall not interrupt or
            otherwise affect the civil service status or privileges
            of the Federal employee.
              (5) Upon the request of the Commission, the head of a
            Federal agency shall provide such technical assistance
            to the Commission as the Commission determines to be
            necessary to carry out its duties.
              (6) The Commission may use the United States mails in
            the same manner and under the same conditions as
            Federal agencies and shall, for purposes of the frank,
            be considered a commission of Congress as described in
            section 3215 of title 39, United States Code.
              (7) The Commission may secure directly from any
            Federal agency information necessary to enable it to
            carry out its duties, if the information may be
            disclosed under section 552 of title 4, United States
            Code. Upon request of the Chairman of the Commission,
            the head of such agency shall furnish such information
            to the Commission.
              (8) Upon the request of the Commission, the
            Administrator of General Services shall provide to the
            Commission on a reimbursable basis such administrative
            support services as the Commission may request.
              (9) For purposes of costs relating to printing and
            binding, including the cost of personnel detailed from
            the Government Printing Office, the Commission shall be
            deemed to be a committee of Congress.
        (i) Authorization of Appropriations.--There is authorized
    to be appropriated $4,000,000 to carry out the provisions of
    this section, which sum shall not be deducted from or affect
    any other appropriation for health care for Indian persons.
        (j) Nonapplicability of FACA.--The Federal Advisory
    Committee Act (5 U.S.C. App.) shall not apply to the
    Commission.

    SEC. 815. CONFIDENTIALITY OF MEDICAL QUALITY ASSURANCE RECORDS;
                        QUALIFIED IMMUNITY FOR PARTICIPANTS.

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

    SEC. 816. APPROPRIATIONS; AVAILABILITY.

        Any new spending authority (described in subparagraph (A)
    or (B) of section 401(c)(2) of the Congressional Budget Act of
    1974 (Public Law 93-344; 88 Stat. 317)) which is provided under
    this Act shall be effective for any fiscal year only to such
    extent or in such amounts as are provided in appropriation
    Acts.

    SEC. 817. AUTHORIZATION OF APPROPRIATIONS.

        ``There are authorized to be appropriated such sums as may
    be necessary for each fiscal year through fiscal year 2017 to
    carry out this title.''
        (b) Rate of Pay.--
              (1) Positions at level iv.--Section 5315 of title 5,
            United States Code, is amended by striking ``Assistant
            Secretaries of Health and Human Services (6).'' and
            inserting ``Assistant Secretaries of Health and Human
            Services (7)''.
              (2) Positions at level v.--Section 5316 of title 5,
            United States Code, is amended by striking ``Director,
            Indian Health Service, Department of Health and Human
            Services''.
        (c) Amendments to Other Provisions of Law.--
              (1) Section 3307(b)(1)(C) of the Children's Health
            Act of 2000 (25 U.S.C. 1671 note; Public Law 106-310)
            is amended by striking ``Director of the Indian Health
            Service'' and inserting ``Assistant Secretary for
            Indian Health''.
              (2) The Indian Lands Open Dump Cleanup Act of 1994 is
            amended--
                      (A) in section 3 (25 U.S.C. 3902)--
                              (i) by striking paragraph (2);
                              (ii) by redesignating paragraphs (1),
                            (3), (4), (5), and (6) as paragraphs
                            (4), (5), (2), (6), and (1),
                            respectively, and moving those
                            paragraphs so as to appear in numerical
                            order; and
                              (iii) by inserting before paragraph
                            (4) (as redesignated by subclause (II))
                            the following:
              ``(3) Assistant Secretary.--The term `Assistant
            Secretary' means the Assistant Secretary for Indian
            Health.'';
                      (B) in section 5 (25 U.S.C. 3904), by
                    striking the section designation and heading
                    and inserting the following:

    ``SEC. 5. AUTHORITY OF ASSISTANT SECRETARY FOR INDIAN HEALTH.'';

                      (C) in section 6(a) (25 U.S.C. 3905(a)), in
                    the subsection heading, by striking
                    ``Director'' and inserting ``Assistant
                    Secretary'';
                      (D) in section 9(a) (25 U.S.C. 3908(a)), in
                    the subsection heading, by striking
                    ``Director'' and inserting ``Assistant
                    Secretary''; and
                      (E) by striking ``Director'' each place it
                    appears and inserting ``Assistant Secretary''.
              (3) Section 5504(d)(2) of the Augustus F. Hawkins-
            Robert T. Stafford Elementary and Secondary School
            Improvement Amendments of 1988 (25 U.S.C. 2001 note;
            Public Law 100-297) is amended by striking ``Director
            of the Indian Health Service'' and inserting
            ``Assistant Secretary for Indian Health''.
              (4) Section 203(a)(1) of the Rehabilitation Act of
            1973 (29 U.S.C. 763(a)(1)) is amended by striking
            ``Director of the Indian Health Service'' and inserting
            ``Assistant Secretary for Indian Health''.
              (5) Subsections (b) and (e) of section 518 of the
            Federal Water Pollution Control Act (33 U.S.C. 1377)
            are amended by striking ``Director of the Indian Health
            Service'' each place it appears and inserting
            ``Assistant Secretary for Indian Health''.
              (6) Section 317M(b) of the Public Health Service Act
            (42 U.S.C. 247b-14(b)) is amended--
                      (A) by striking ``Director of the Indian
                    Health Service'' each place it appears and
                    inserting ``Assistant Secretary for Indian
                    Health''; and
                      (B) in paragraph (2)(A), by striking ``the
                    Directors referred to in such paragraph'' and
                    inserting ``the Director of the Centers for
                    Disease Control and Prevention and the
                    Assistant Secretary for Indian Health''.
              (7) Section 417C(b) of the Public Health Service Act
            (42 U.S.C. 285-9(b)) is amended by striking ``Director
            of the Indian Health Service'' and inserting
            ``Assistant Secretary for Indian Health''.
              (8) Section 1452(i) of the Safe Drinking Water Act
            (42 U.S.C. 300j-12(i)) is amended by striking
            ``Director of the Indian Health Service'' each place it
            appears and inserting ``Assistant Secretary for Indian
            Health''.
              (9) Section 803B(d)(1) of the Native American
            Programs Act of 1974 (42 U.S.C. 2991b-2(d)(1)) is
            amended in the last sentence by striking ``Director of
            the Indian Health Service'' and inserting ``Assistant
            Secretary for Indian Health''.
              (10) Section 203(b) of the Michigan Indian Land
            Claims Settlement Act (Public Law 105-143; 111 Stat.
            2666) is amended by striking ``Director of the Indian
            Health Service'' and inserting ``Assistant Secretary
            for Indian Health''.

    SEC. 102. SOBOBA SANITATION FACILITIES.

        The Act of December 17, 1970 (84 Stat. 1465), is amended by
    adding at the end the following:
        ``Sec. 9. Nothing in this Act shall preclude the Soboba
    Band of Mission Indians and the Soboba Indian Reservation from
    being provided with sanitation facilities and services under
    the authority of section 7 of the Act of August 5, 1954 (68
    Stat. 674), as amended by the Act of July 31, 1959 (73 Stat.
    267).''.

    SEC. 103. NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION.

        (a) In General.--The Indian Self-Determination and
    Education Assistance Act (25 U.S.C. 450 et seq.) is amended by
    adding at the end the following:

          ``TITLE VIII--NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION

    ``SEC. 801. DEFINITIONS.

        ``In this title:
              ``(1) Board.--The term `Board' means the Board of
            Directors of the Foundation.
              ``(2) Committee.--The term `Committee' means the
            Committee for the Establishment of Native American
            Health and Wellness Foundation established under
            section 802(f).
              ``(3) Foundation.--The term `Foundation' means the
            Native American Health and Wellness Foundation
            established under section 802.
              ``(4) Secretary.--The term `Secretary' means the
            Secretary of Health and Human Services.
              ``(5) Service.--The term `Service' means the Indian
            Health Service of the Department of Health and Human
            Services.

    ``SEC. 802. NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION.

        ``(a) Establishment.--
              ``(1) In general.--As soon as practicable after the
            date of enactment of this title, the Secretary shall
            establish, under the laws of the District of Columbia
            and in accordance with this title, the Native American
            Health and Wellness Foundation.
              ``(2) Funding determinations.--No funds, gift,
            property, or other item of value (including any
            interest accrued on such an item) acquired by the
            Foundation shall--
                      ``(A) be taken into consideration for
                    purposes of determining Federal appropriations
                    relating to the provision of health care and
                    services to Indians; or
                      ``(B) otherwise limit, diminish, or affect
                    the Federal responsibility for the provision of
                    health care and services to Indians.
        ``(b) Perpetual Existence.--The Foundation shall have
    perpetual existence.
        ``(c) Nature of Corporation.--The Foundation--
              ``(1) shall be a charitable and nonprofit federally
            chartered corporation; and
              ``(2) shall not be an agency or instrumentality of
            the United States.
        ``(d) Place of Incorporation and Domicile.--The Foundation
    shall be incorporated and domiciled in the District of
    Columbia.
        ``(e) Duties.--The Foundation shall--
              ``(1) encourage, accept, and administer private gifts
            of real and personal property, and any income from or
            interest in such gifts, for the benefit of, or in
            support of, the mission of the Service;
              ``(2) undertake and conduct such other activities as
            will further the health and wellness activities and
            opportunities of Native Americans; and
              ``(3) participate with and assist Federal, State, and
            tribal governments, agencies, entities, and individuals
            in undertaking and conducting activities that will
            further the health and wellness activities and
            opportunities of Native Americans.
        ``(f) Committee for the Establishment of Native American
    Health and Wellness Foundation.--
              ``(1) In general.--The Secretary shall establish the
            Committee for the Establishment of Native American
            Health and Wellness Foundation to assist the Secretary
            in establishing the Foundation.
              ``(2) Duties.--Not later than 180 days after the date
            of enactment of this section, the Committee shall--
                      ``(A) carry out such activities as are
                    necessary to incorporate the Foundation under
                    the laws of the District of Columbia, including
                    acting as incorporators of the Foundation;
                      ``(B) ensure that the Foundation qualifies
                    for and maintains the status required to carry
                    out this section, until the Board is
                    established;
                      ``(C) establish the constitution and initial
                    bylaws of the Foundation;
                      ``(D) provide for the initial operation of
                    the Foundation, including providing for
                    temporary or interim quarters, equipment, and
                    staff; and
                      ``(E) appoint the initial members of the
                    Board in accordance with the constitution and
                    initial bylaws of the Foundation.
        ``(g) Board of Directors.--
              ``(1) In general.--The Board of Directors shall be
            the governing body of the Foundation.
              ``(2) Powers.--The Board may exercise, or provide for
            the exercise of, the powers of the Foundation.
              ``(3) Selection.--
                      ``(A) In general.--Subject to subparagraph
                    (B), the number of members of the Board, the
                    manner of selection of the members (including
                    the filling of vacancies), and the terms of
                    office of the members shall be as provided in
                    the constitution and bylaws of the Foundation.
                      ``(B) Requirements.--
                              ``(i) Number of members.--The Board
                            shall have at least 11 members, who
                            shall have staggered terms.
                              ``(ii) Initial voting members.--The
                            initial voting members of the Board--
                                      ``(I) shall be appointed by
                                    the Committee not later than
                                    180 days after the date on
                                    which the Foundation is
                                    established; and
                                      ``(II) shall have staggered
                                    terms.
                              ``(iii) Qualification.--The members
                            of the Board shall be United States
                            citizens who are knowledgeable or
                            experienced in Native American health
                            care and related matters.
                      ``(C) Compensation.--A member of the Board
                    shall not receive compensation for service as a
                    member, but shall be reimbursed for actual and
                    necessary travel and subsistence expenses
                    incurred in the performance of the duties of
                    the Foundation.
        ``(h) Officers.--
              ``(1) In general.--The officers of the Foundation
            shall be--
                      ``(A) a secretary, elected from among the
                    members of the Board; and
                      ``(B) any other officers provided for in the
                    constitution and bylaws of the Foundation.
              ``(2) Chief operating officer.--The secretary of the
            Foundation may serve, at the direction of the Board, as
            the chief operating officer of the Foundation, or the
            Board may appoint a chief operating officer, who shall
            serve at the direction of the Board.
              ``(3) Election.--The manner of election, term of
            office, and duties of the officers of the Foundation
            shall be as provided in the constitution and bylaws of
            the Foundation.
        ``(i) Powers.--The Foundation--
              ``(1) shall adopt a constitution and bylaws for the
            management of the property of the Foundation and the
            regulation of the affairs of the Foundation;
              ``(2) may adopt and alter a corporate seal;
              ``(3) may enter into contracts;
              ``(4) may acquire (through a gift or otherwise), own,
            lease, encumber, and transfer real or personal property
            as necessary or convenient to carry out the purposes of
            the Foundation;
              ``(5) may sue and be sued; and
              ``(6) may perform any other act necessary and proper
            to carry out the purposes of the Foundation.
        ``(j) Principal Office.--
              ``(1) In general.--The principal office of the
            Foundation shall be in the District of Columbia.
              ``(2) Activities; offices.--The activities of the
            Foundation may be conducted, and offices may be
            maintained, throughout the United States in accordance
            with the constitution and bylaws of the Foundation.
        ``(k) Service of Process.--The Foundation shall comply with
    the law on service of process of each State in which the
    Foundation is incorporated and of each State in which the
    Foundation carries on activities.
        ``(l) Liability of Officers, Employees, and Agents.--
              ``(1) In general.--The Foundation shall be liable for
            the acts of the officers, employees, and agents of the
            Foundation acting within the scope of their authority.
              ``(2) Personal liability.--A member of the Board
            shall be personally liable only for gross negligence in
            the performance of the duties of the member.
        ``(m) Restrictions.--
              ``(1) Limitation on spending.--Beginning with the
            fiscal year following the first full fiscal year during
            which the Foundation is in operation, the
            administrative costs of the Foundation shall not exceed
            the percentage described in paragraph (2) of the sum
            of--
                      ``(A) the amounts transferred to the
                    Foundation under subsection (o) during the
                    preceding fiscal year; and
                      ``(B) donations received from private sources
                    during the preceding fiscal year.
              ``(2) Percentages.--The percentages referred to in
            paragraph (1) are--
                      ``(A) for the first fiscal year described in
                    that paragraph, 20 percent;
                      ``(B) for the following fiscal year, 15
                    percent; and
                      ``(C) for each fiscal year thereafter, 10
                    percent.
              ``(3) Appointment and hiring.--The appointment of
            officers and employees of the Foundation shall be
            subject to the availability of funds.
              ``(4) Status.--A member of the Board or officer,
            employee, or agent of the Foundation shall not by
            reason of association with the Foundation be considered
            to be an officer, employee, or agent of the United
            States.
        ``(n) Audits.--The Foundation shall comply with section
    10101 of title 36, United States Code, as if the Foundation
    were a corporation under part B of subtitle II of that title.
        ``(o) Funding.--
              ``(1) Authorization of appropriations.--There is
            authorized to be appropriated to carry out subsection
            (e)(1) $500,000 for each fiscal year, as adjusted to
            reflect changes in the Consumer Price Index for all-
            urban consumers published by the Department of Labor.
              ``(2) Transfer of donated funds.--The Secretary shall
            transfer to the Foundation funds held by the Department
            of Health and Human Services under the Act of August 5,
            1954 (42 U.S.C. 2001 et seq.), if the transfer or use
            of the funds is not prohibited by any term under which
            the funds were donated.

    ``SEC. 803. ADMINISTRATIVE SERVICES AND SUPPORT.

        ``(a) Provision of Support by Secretary.--Subject to
    subsection (b), during the 5-year period beginning on the date
    on which the Foundation is established, the Secretary--
              ``(1) may provide personnel, facilities, and other
            administrative support services to the Foundation;
              ``(2) may provide funds for initial operating costs
            and to reimburse the travel expenses of the members of
            the Board; and
              ``(3) shall require and accept reimbursements from
            the Foundation for--
                      ``(A) services provided under paragraph (1);
                    and
                      ``(B) funds provided under paragraph (2).
        ``(b) Reimbursement.--Reimbursements accepted under
    subsection (a)(3)--
              ``(1) shall be deposited in the Treasury of the
            United States to the credit of the applicable
            appropriations account; and
              ``(2) shall be chargeable for the cost of providing
            services described in subsection (a)(1) and travel
            expenses described in subsection (a)(2).
        ``(c) Continuation of Certain Services.--The Secretary may
    continue to provide facilities and necessary support services
    to the Foundation after the termination of the 5-year period
    specified in subsection (a) if the facilities and services--
              ``(1) are available; and
              ``(2) are provided on reimbursable cost basis.''
        (b) Technical Amendments.--The Indian Self-Determination
    and Education Assistance Act is amended--
              (1) by redesignating title V (25 U.S.C. 458bbb et
            seq.) as title VII;
              (2) by redesignating sections 501, 502, and 503 (25
            U.S.C. 458bbb, 458bbb-1, 458bbb-2) as sections 701,
            702, and 703, respectively; and
              (3) in subsection (a)(2) of section 702 and paragraph
            (2) of section 703 (as redesignated by paragraph (2)),
            by striking ``section 501'' and inserting ``section
            701''.

     TITLE II--IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER THE SOCIAL
                                  SECURITY ACT

    SEC. 201. EXPANSION OF PAYMENTS UNDER MEDICARE, MEDICAID, AND SCHIP FOR
                        ALL COVERED SERVICES FURNISHED BY INDIAN HEALTH
                        PROGRAMS.

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

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

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

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

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

    SEC. 202. INCREASED OUTREACH TO INDIANS UNDER MEDICAID AND SCHIP AND
                        IMPROVED COOPERATION IN THE PROVISION OF ITEMS AND
                        SERVICES TO INDIANS UNDER SOCIAL SECURITY ACT
                        HEALTH BENEFIT PROGRAMS.

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

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

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

    SEC. 203. ADDITIONAL PROVISIONS TO INCREASE OUTREACH TO, AND ENROLLMENT
                        OF, INDIANS IN SCHIP AND MEDICAID.

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

    SEC. 204. PREMIUMS AND COST SHARING PROTECTIONS UNDER MEDICAID,
                        ELIGIBILITY DETERMINATIONS UNDER MEDICAID AND
                        SCHIP, AND PROTECTION OF CERTAIN INDIAN PROPERTY
                        FROM MEDICAID ESTATE RECOVERY.

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

    SEC. 205. NONDISCRIMINATION IN QUALIFICATIONS FOR PAYMENT FOR SERVICES
                        UNDER FEDERAL HEALTH CARE PROGRAMS.

        Section 1139 of the Social Security Act (42 U.S.C. 1320b-
    9), as amended by section 202, is amended by redesignating
    subsection (c) as subsection (d), and inserting after
    subsection (b) the following new subsection:
        ``(c) Nondiscrimination in Qualifications for Payment for
    Services Under Federal Health Care Programs.--
              ``(1) Requirement to satisfy generally applicable
            participation requirements.--
                      (A) In general.--A Federal health care
                    program must accept an entity that is operated
                    by the Indian Health Service, an Indian Tribe,
                    Tribal Organization, or Urban Indian
                    Organization as a provider eligible to receive
                    payment under the program for health care
                    services furnished to an Indian on the same
                    basis as any other provider qualified to
                    participate as a provider of health care
                    services under the program if the entity meets
                    generally applicable State or other
                    requirements for participation as a provider of
                    health care services under the program.
                      ``(B) Satisfaction of state or local
                    licensure or recognition requirements.--Any
                    requirement for participation as a provider of
                    health care services under a Federal health
                    care program that an entity be licensed or
                    recognized under the State or local law where
                    the entity is located to furnish health care
                    services shall be deemed to have been met in
                    the case of an entity operated by the Indian
                    Health Service, an Indian Tribe, Tribal
                    Organization, or Urban Indian Organization if
                    the entity meets all the applicable standards
                    for such licensure or recognition, regardless
                    of whether the entity obtains a license or
                    other documentation under such State or local
                    law. In accordance with section 221 of the
                    Indian Health Care Improvement Act, the absence
                    of the licensure of a health care professional
                    employed by such an entity under the State or
                    local law where the entity is located shall not
                    be taken into account for purposes of
                    determining whether the entity meets such
                    standards, if the professional is licensed in
                    another State.
              ``(2) Prohibition on federal payments to entities or
            individuals excluded from participation in federal
            health care programs or whose state licenses are under
            suspension or have been revoked.--
                      ``(A) Excluded entities.--No entity operated
                    by the Indian Health Service, an Indian Tribe,
                    Tribal Organization, or Urban Indian
                    Organization that has been excluded from
                    participation in any Federal health care
                    program or for which a license is under
                    suspension or has been revoked by the State
                    where the entity is located shall be eligible
                    to receive payment under any such program for
                    health care services furnished to an Indian.
                      ``(B) Excluded individuals.--No individual
                    who has been excluded from participation in any
                    Federal health care program or whose State
                    license is under suspension or has been revoked
                    shall be eligible to receive payment under any
                    such program for health care services furnished
                    by that individual, directly or through an
                    entity that is otherwise eligible to receive
                    payment for health care services, to an Indian.
                      ``(C) Federal health care program defined.--
                    In this subsection, the term, `Federal health
                    care program' has the meaning given that term
                    in section 1128B(f), except that, for purposes
                    of this subsection, such term shall include the
                    health insurance program under chapter 89 of
                    title 5, United States Code.''.

    SEC. 206. CONSULTATION ON MEDICAID, SCHIP, AND OTHER HEALTH CARE
                        PROGRAMS FUNDED UNDER THE SOCIAL SECURITY ACT
                        INVOLVING INDIAN HEALTH PROGRAMS AND URBAN INDIAN
                        ORGANIZATIONS.

        (a) In General.--Section 1139 of the Social Security Act
    (42 U.S.C. 1320b-9), as amended by sections 202 and 205, is
    amended by redesignating subsection (d) as subsection (e), and
    inserting after subsection (c) the following new subsection:
        ``(d) Consultation With Tribal Technical Advisory Group
    (TTAG).--The Secretary shall maintain within the Centers for
    Medicaid & Medicare Services (CMS) a Tribal Technical Advisory
    Group, established in accordance with requirements of the
    charter dated September 30, 2003, and in such group shall
    include a representative of the Urban Indian Organizations and
    the Service. The representative of the Urban Indian
    Organization shall be deemed to be an elected officer of a
    tribal government for purposes of applying section 204(b) of
    the Unfunded Mandates Reform Act of 1995 (2 U.S.C. 1534(b)).''.
        (b) Solicitation of Advice Under Medicaid and SCHIP.--
              (1) Medicaid state plan amendment.--Section 1902(a)
            of the Social Security Act (42 U.S.C. 1396a(a)) is
            amended--
                      (A) in paragraph (69), by striking `and' at
                    the end;
                      (B) in paragraph (70)(B)(iv), by striking the
                    period at the end and inserting `; and'; and
                      (C) by inserting after paragraph (70)(B)(iv),
                    the following new paragraph:
              ``(71) in the case of any State in which the Indian
            Health Service operates or funds health care programs,
            or in which 1 or more Indian Health Programs or Urban
            Indian Organizations (as such terms are defined in
            section 4 of the Indian Health Care Improvement Act)
            provide health care in the State for which medical
            assistance is available under such title, provide for a
            process under which the State seeks advice on a
            regular, ongoing basis from designees of such Indian
            Health Programs and Urban Indian Organizations on
            matters relating to the application of this title that
            are likely to have a direct effect on such Indian
            Health Programs and Urban Indian Organizations and
            that--
                      ``(A) shall include solicitation of advice
                    prior to submission of any plan amendments,
                    waiver requests, and proposals for
                    demonstration projects likely to have a direct
                    effect on Indians, Indian Health Programs, or
                    Urban Indian Organizations; and
                      ``(B) may include appointment of an advisory
                    committee and of a designee of such Indian
                    Health Programs and Urban Indian Organizations
                    to the medical care advisory committee advising
                    the State on its State plan under this
                    title.''.
              (2) Application to schip.--Section 2107(e)(1) of such
            Act (42 U.S.C. 1397gg(e)(1)), as amended by section
            204(b)(2), is amended--
                    (A) by redesignating subparagraphs (B) through
                    (F) as subparagraphs (C) through (G),
                    respectively; and
                      (B) by inserting after subparagraph (A), the
                    following new subparagraph:
                      ``(B) Section 1902(a)(71) (relating to the
                    option of certain States to seek advice from
                    designees of Indian Health Programs and Urban
                    Indian Organizations).''.
        (c) Rule of Construction.--Nothing in the amendments made
    by this section shall be construed as superseding existing
    advisory committees, working groups, guidance, or other
    advisory procedures established by the Secretary of Health and
    Human Services or by any State with respect to the provision of
    health care to Indians.

    SEC. 207. EXCLUSION WAIVER AUTHORITY FOR AFFECTED INDIAN HEALTH
                        PROGRAMS AND SAFE HARBOR TRANSACTIONS UNDER THE
                        SOCIAL SECURITY ACT.

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

    SEC. 208. RULES APPLICABLE UNDER MEDICAID AND SCHIP TO MANAGED CARE
                        ENTITIES WITH RESPECT TO INDIAN ENROLLEES AND
                        INDIAN HEALTH CARE PROVIDERS AND INDIAN MANAGED
                        CARE ENTITIES.

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

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

                      ``(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) Establishment; grants
              [(1) The Secretary, acting through the Service, shall
            make grants to Indian tribes to establish demonstration
            projects under which the Indian tribe will develop and
            test a phased approach to assumption by the Indian
            tribe of the health care delivery system of the Service
            for members of the Indian tribe living on or near the
            reservations of the Indian tribe through the use of
            Service, tribal, and private sector resources.
              [(2) A grant may be awarded to an Indian tribe under
            paragraph (1) only if the Secretary determines that the
            Indian tribe has the administrative and financial
            capabilities necessary to conduct a demonstration
            project described in paragraph (1).
        [(b) Health care contracts
        [During the period in which a demonstration project
    established under subsection (a) of this section is being
    conducted by an Indian tribe, the Secretary shall award all
    health care contracts, including community, behavioral, and
    preventive health care contracts, to the Indian tribe in the
    form of a single grant to which the regulations prescribed
    under part A of title XIX of the Public Health Service Act [42
    U.S.C.A. Sec. 300w et seq.] (as modified as necessary by any
    agreement entered into between the Secretary and the Indian
    tribe to achieve the purposes of the demonstration project
    established under subsection (a) of this section) shall apply.
        [(c) Waiver of procurement laws
        [The Secretary may waive such provisions of Federal
    procurement law as are necessary to enable any Indian tribe to
    develop and test administrative systems under the demonstration
    project established under subsection (a) of this section, but
    only if such waiver does not diminish or endanger the delivery
    of health care services to Indians.
        [(d) Termination; evaluation and report
              [(1) The demonstration project established under
            subsection (a) of this section shall terminate on
            September 30, 1993, or, in the case of a demonstration
            project for which a grant is made after September 30,
            1990, three years after the date on which such grant is
            made.
              [(2) By no later than September 30, 1996, the
            Secretary shall evaluate the performance of each Indian
            tribe that has participated in a demonstration project
            established under subsection (a) of this section and
            shall submit to the Congress a report on such
            evaluations and demonstration projects.
        [(e) Joint venture demonstration projects
              [(1) The Secretary, acting through the Service, shall
            make arrangements with Indian tribes to establish joint
            venture demonstration projects under which an Indian
            tribe shall expend tribal, private, or other available
            nontribal funds, for the acquisition or construction of
            a health facility for a minimum of 20 years, under a
            no-cost lease, in exchange for agreement by the Service
            to provide the equipment, supplies, and staffing for
            the operation and maintenance of such a health
            facility. A tribe may utilize tribal funds, private
            sector, or other available resources, including loan
            guarantees, to fulfill its commitment under this
            subsection.
              [(2) The Secretary shall make such an arrangement
            with an Indian tribe only if the Secretary first
            determines that the Indian tribe has the administrative
            and financial capabilities necessary to complete the
            timely acquisition or construction of the health
            facility described in paragraph (1).
              [(3) An Indian tribe or tribal organization that has
            entered into a written agreement with the Secretary
            under this subsection, and that breaches or terminates
            without cause such agreement, shall be liable to the
            United States for the amount that has been paid to the
            tribe, or paid to a third party on the tribe's behalf,
            under the agreement. The Secretary has the right to
            recover tangible property (including supplies), and
            equipment, less depreciation, and any funds expended
            for operations and maintenance under this section. The
            preceding sentence does not apply to any funds expended
            for the delivery of health care services, or for
            personnel or staffing, shall be recoverable.]
                      ``(A) a Federally-qualified health center
                    that is covered under the Federal Tort Claims
                    Act (28 U.S.C. 1346(b), 2671 et seq.);

    [Sec. 1680i. Child sexual abuse treatment programs]

                      ``(B) providing health care services pursuant
                    to a contract or compact under the Indian Self-
                    Determination and Education Assistance Act (25
                    U.S.C. 450 et seq.) that are covered under the
                    Federal Tort Claims Act (28 U.S.C. 1346(b),
                    2671 et seq.); or
        [(a) Continuation of existing demonstration programs
        [The Secretary and the Secretary of the Interior shall, for
    each fiscal year through fiscal year 1995, continue the
    demonstration programs involving treatment for child sexual
    abuse provided through the Hopi Tribe and the Assiniboine and
    Sioux Tribes of the Fort Peck Reservation.
        [(b) Establishment of new demonstration programs
        [Beginning October 1, 1995, the Secretary and the Secretary
    of the Interior may establish, in any service area,
    demonstration programs involving treatment for child sexual
    abuse, except that the Secretaries may not establish a greater
    number of such programs in one service area than in any other
    service area until there is an equal number of such programs
    established with respect to all service areas from which the
    Secretary receives qualified applications during the
    application period (as determined by the Secretary).]
                      ``(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.);

    [Sec. 1680j. Tribal leasing]

    are deemed to satisfy such requirement.
        [Indian tribes providing health care services pursuant to a
    contract entered into under the Indian Self-Determination Act
    [25 U.S.C.A. Sec. 450f et seq.] may lease permanent structures
    for the purpose of providing such health care services without
    obtaining advance approval in appropriation Acts.]
             ``(6) Definitions.--For purposes of this subsection:

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

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

    [Sec. 1680l. Shared services demonstration project]

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

    [Sec. 1680m. Results of demonstration projects]

                      ``(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.
        [The Secretary shall provide for the dissemination to
    Indian tribes of the findings and results of demonstration
    projects conducted under this chapter.]
                      ``(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.''.

    [Sec. 1680n. Priority for Indian reservations]

        (b) Application to SCHIP.--Section 2107(e)(1) of such Act
    (42 U.S.C. 1397gg(1)), as amended by section 206(b)(2), is
    amended by adding at the end the following new subparagraph:
        [(a) Facilities and projects
        [Beginning on October 29, 1992, the Bureau of Indian
    Affairs and the Service shall, in all matters involving the
    reorganization or development of Service facilities, or in the
    establishment of related employment projects to address
    unemployment conditions in economically depressed areas, give
    priority to locating such facilities and projects on Indian
    lands if requested by the Indian tribe with jurisdiction over
    such lands.
        [(b) ``Indian lands'' defined
        [For purposes of this section, the term ``Indian lands''
    means--
              [(1) all lands within the limits of any Indian
            reservation; and
              [(2) any lands title which is held in trust by the
            United States for the benefit of any Indian tribe or
            individual Indian, or held by any Indian tribe or
            individual Indian subject to restriction by the United
            States against alienation and over which an Indian
            tribe exercises governmental power.]
                      ``(H) Subsections (a)(2)(C) and (h) of
                    section 1932.''.

    [Sec. 1680o. Authorization of appropriations]

    SEC. 209. ANNUAL REPORT ON INDIANS SERVED BY SOCIAL SECURITY ACT HEALTH
                        BENEFIT PROGRAMS.

        [Except as provided in section 1680k of this title, there
    are authorized to be appropriated such sums as may be necessary
    for each fiscal year through fiscal year 2000 to carry out this
    subchapter.]
        Section 1139 of the Social Security Act (42 U.S.C. 1320b-
    9), as amended by the sections 202, 205, and 206, is amended by
    redesignating subsection (e) as subsection (f), and inserting
    after subsection (d) the following new subsection:

    [Sec. 1681. Billing of Indians by Indian Health Service]

        ``(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:
        [The Indian Health Service shall neither bill nor charge
    those Indians who may have the economic means to pay unless and
    until such time as Congress has agreed upon a specific policy
    to do so and has directed the Indian Health Service to
    implement such a policy.]
              ``(1) The total number of Indians enrolled in, or
            receiving items or services under, such programs,
            disaggregated with respect to each such program.

    [Sec. 1682. Subrogation of claims by]

              ``(2) The number of Indians described in paragraph
            (1) that also received health benefits under programs
            funded by the Indian Health Service.
        [Hereafter the Indian Health Service may seek subrogation
    of claims including but not limited to auto accident claims,
    including no-fault claims, personal injury, disease, or
    disability claims, and worker's compensation claims, the
    proceeds of which shall be credited to the funds established by
    sections 401 and 402 of the Indian Health Care Improvement
    Act.]
              ``(3) General information regarding the health status
            of the Indians described in paragraph (1),
            disaggregated with respect to specific diseases or
            conditions and presented in a manner that is consistent
            with protections for privacy of individually
            identifiable health information under section 264(c) of
            the Health Insurance Portability and Accountability Act
            of 1996.

    [Sec. 1683. Indian Catastrophic Health Emergency Fund]

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