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Indian Health Care Provisions in H.R. 3962
Roger Walke
Specialist in American Indian Policy
Elayne J. Heisler
Analyst in Health Services
November 6, 2009
Congressional Research Service
7-5700
www.crs.gov
R40902
CRS Report for Congress
P
repared for Members and Committees of Congress
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Indian Health Care Provisions in H.R. 3962
Summary
The 111th Congress has devoted considerable effort to health reform that seeks to increase health
insurance coverage for more Americans and help control increasing costs while improving quality
and patient outcomes. H.R. 3962, the Affordable Health Care for America Act, was introduced in
the House of Representatives on October 29, 2009. H.R. 3962 is based on H.R. 3200, America’s
Affordable Health Choices Act of 2009, which was originally introduced on July 14, 2009, and
was reported separately on October 14, 2009, by three House Committees—Education and Labor,
Energy and Commerce, and Ways and Means. One major difference between H.R. 3200 and H.R.
3962 is the addition of Division D, “Indian Health Care Improvement,” which would reenact,
authorize, and amend the Indian Health Care Improvement Act (IHCIA). Division D differs from
much of the other divisions of H.R. 3962 in that it targets a specific population group—American
Indians and Alaska Natives, a group that, in general, has lower health status, lower life
expectancy, and higher rates of a number of diseases, including diabetes, than the U.S. population
as a whole. The goal of the division—to improve the health of American Indians and Alaska
Natives—is consistent with the changes proposed in other divisions that also propose to improve
health care access and quality, augment the health care workforce, and increase access to mental
health services.
This report summarizes the provisions of Division D of H.R. 3962. The division contains two
titles. Title I contains three sections (3101-3103), of which Section 3101(a) reenacts, amends, and
reauthorizes all eight titles of IHCIA. Section 3101(a) contains IHCIA’s general provisions and its
eight titles: (1) Indian health workforce, (2) health services, (3) health care and sanitation
facilities, (4) access to federal reimbursements, (5) health services for urban Indians, (6) Indian
Health Service (IHS) organizational improvements, (7) behavioral health programs, and (8)
miscellaneous. Section 3101(b) and (c) and Sections 3102 and 3103 make changes to Indian
programs, including technical corrections to other federal laws. Title II of Division D contains
five sections (Sections 3201-3205), three of which amend the Social Security Act (SSA) as
related to American Indians and Alaska Natives. None of these sections amend IHCIA.
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Indian Health Care Provisions in H.R. 3962
Contents
Introduction ................................................................................................................................ 1
Overview of Indian Health Care.................................................................................................. 1
Overview of Report..................................................................................................................... 2
Title I of Division D: IHCIA Reauthorization .............................................................................. 4
Federal Indian Health Policy and IHCIA Definitions ............................................................. 4
Section 3. Declaration of National Indian Health Policy .................................................. 4
Section 4. Definitions...................................................................................................... 4
Indian Health Workforce ....................................................................................................... 5
Section 102. Health Professions Recruitment Program for Indians ................................... 5
Section 103. Health Professions Preparatory Scholarship Program for Indians ................. 5
Section 104. Indian Health Professions Scholarships ....................................................... 5
Section 105. American Indians into Psychology Program ................................................ 6
Section 106. Scholarship Programs for Indian Tribes ....................................................... 6
Section 107. Indian Health Service Extern Programs ....................................................... 6
Section 108. Continuing Education Allowances............................................................... 6
Section 109. Community Health Representative Program ................................................ 7
Section 110. Indian Health Service Loan Repayment Program......................................... 7
Section 111. Scholarship and Loan Repayment Recovery Fund ....................................... 7
Section 113. Indian Recruitment and Retention Program ................................................. 7
Section 114. Advanced Training and Research................................................................. 8
Section 115. Quentin N. Burdick American Indians into Nursing Program....................... 8
Section 116. Tribal Cultural Orientation .......................................................................... 8
Section 117. INMED Program......................................................................................... 8
Section 118. Health Training Programs of Community Colleges ...................................... 8
Section 119. Retention Bonus.......................................................................................... 9
Section 120. Nursing Residency Program........................................................................ 9
Section 121. Community Health Aide Program ............................................................... 9
Section 122. Tribal Health Program Administration ....................................................... 10
Section 123. Health Professional Chronic Shortage Demonstration Programs ................ 10
Section 124. National Health Service Corps .................................................................. 10
Section 125. Substance Abuse Counselor Educational Demonstration Programs ............ 10
Section 126. Behavioral Health Training and Community Education Programs.............. 10
Section 127. Exemption from Payment of Certain Fees ................................................. 11
Health Services ................................................................................................................... 11
Section 201. Indian Health Care Improvement Fund...................................................... 11
Section 202. Health Promotion and Disease Prevention Services ................................... 11
Section 203. Diabetes Prevention, Treatment, and Control............................................. 12
Section 204. Shared Services for Long-term Care.......................................................... 12
Section 205. Health Services Research .......................................................................... 12
Section 206. Mammography and Other Cancer Screening ............................................. 13
Section 207. Patient Travel Costs .................................................................................. 13
Section 208. Epidemiology Centers ............................................................................... 13
Section 209. Comprehensive School Health Education Programs .................................. 13
Section 210. Indian Youth Program ............................................................................... 14
Section 211. Projects Related to Communicable and Infectious Diseases ....................... 14
Section 212. Other Authority for Provision of Services .................................................. 14
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Section 213. Indian Women’s Health Care..................................................................... 15
Section 214. Environmental and Nuclear Health Hazards .............................................. 15
Section 217. California Contract Health Services Program ............................................ 15
Section 221. Licensing .................................................................................................. 16
Section 222. Notification of Provision of Emergency Contract Health Services ............. 16
Section 223. Prompt Action on Payment of Claims........................................................ 16
Section 224. Liability for Payment ................................................................................ 16
Section 225. Office of Indian Men’s Health................................................................... 16
Section 226. Catastrophic Health Emergency Fund........................................................ 16
Health Care and Sanitation Facilities ................................................................................... 17
Section 301. Consultation; Construction and Renovation of Facilities; Reports.............. 17
Section 302. Sanitation Facilities................................................................................... 18
Section 303. Preference to Indians and Indian Firms...................................................... 19
Section 304. Expenditure of Non-Service Funds for Renovation.................................... 19
Section 305. Funding for Small Ambulatory Care Facilities........................................... 19
Section 306. Indian Health Care Delivery Demonstration Project .................................. 20
Section 308. Leases, Contracts and Other Agreements ................................................... 20
Section 309. Study on Loans, Loan Guarantees, and Loan Repayment........................... 20
Section 311. Indian Health Service/Tribal Facilities Joint Venture Program ................... 20
Section 312. Location of Facilities ................................................................................ 21
Section 313. Maintenance and Improvement of Health Care Facilities ........................... 21
Section 314. Tribal Management of Federally Owned Quarters ..................................... 21
Section 315. Applicability of Buy American Act Requirement ....................................... 22
Section 316. Other Funding for Facilities ...................................................................... 22
Access To Federal Health Services and Reimbursements..................................................... 22
Section 401. Treatment of Payments under SSA Health Benefits Programs.................... 23
Section 402. SSA Health Benefit Programs Outreach and Enrollment Grants................. 23
Section 403. Third Parties Reimbursements................................................................... 24
Section 404. Crediting of Reimbursements .................................................................... 25
Section 405. Purchasing Health Care Coverage ............................................................. 25
Section 406. Sharing Arrangements with Federal Agencies............................................ 25
Section 407. Eligible Indian Veteran Services ................................................................ 25
Section 408. Payor of Last Resort.................................................................................. 26
Section 413. Navajo Nation Medicaid Agency Feasibility Study .................................... 26
Health Services for Urban Indians ....................................................................................... 26
Section 502. Contracts With, and Grants To, Urban Indian Organizations ...................... 27
Section 503. Contracts and Grants for Health Care and Referral Services ...................... 27
Section 504. Use of Federal Government Facilities and Sources of Supply .................... 27
Section 505. Contracts and Grants to Determine Unmet Health Care Needs................... 27
Section 506. Evaluations and Renewals ......................................................................... 28
Section 507. Other Contract and Grant Requirements .................................................... 28
Section 508. Reports and Records ................................................................................. 28
Section 510. Facilities ................................................................................................... 28
Section 511. Division of Urban Indian Health................................................................ 29
Section 512. Grants for Alcohol and Substance Abuse-Related Services ........................ 29
Section 515. Conferring with Urban Indian Organizations ............................................. 29
Section 516. Urban Youth Treatment Center Demonstration .......................................... 29
Section 517. Grants for Diabetes Prevention, Treatment and Control ............................. 29
Section 518. Community Health Representatives........................................................... 29
Section 521. Authorization of Appropriations ................................................................ 29
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Section 522. Health Information Technology ................................................................. 30
Organizational Improvements ............................................................................................. 30
Section 601. Establishment of IHS as a PHS Agency..................................................... 30
Section 602. Automated Management Information System ............................................ 30
Behavioral Health Programs................................................................................................ 31
Section 701. Behavioral Health Prevention and Treatment Services ............................... 31
Section 702. Memoranda of Agreement with the Department of the Interior .................. 31
Section 703. Behavioral Health Prevention and Treatment Program............................... 32
Section 704. Mental Health Technician Program ........................................................... 32
Section 705. Licensing Requirement for Mental Health Care Workers ........................... 32
Section 706. Indian Women Treatment Programs........................................................... 32
Section 707. Indian Youth Program ............................................................................... 32
Section 708. Indian Youth Telemental Health Demonstration Project ............................. 33
Section 709. Mental Health Facilities Design, Construction, and Staffing ...................... 34
Section 710. Training and Community Education .......................................................... 34
Section 711. Behavioral Health Program ....................................................................... 34
Section 712. Fetal Alcohol Disorder Programs .............................................................. 34
Section 713. Child Sexual Abuse and Prevention Treatment Programs........................... 35
Section 714. Domestic and Sexual Violence Prevention and Treatment.......................... 35
Section 715. Behavioral Health Research ...................................................................... 35
Miscellaneous ..................................................................................................................... 36
Section 801. Reports ..................................................................................................... 36
Section 802. Regulations ............................................................................................... 36
Section 803. Plan of Implementation ............................................................................. 36
Section 804. Limitation on Use of Funds Appropriated to Indian Health Service............ 36
Section 805. Eligibility of California Indians ................................................................. 37
Section 806. Health Services for Ineligible Persons ....................................................... 37
Section 807. Reallocation of Base Services ................................................................... 37
Section 809. Moratorium............................................................................................... 38
Section 812. Use of Patient Safety Organizations .......................................................... 38
Section 813. Medical Quality Assurance Records Confidentiality .................................. 38
Section 817. Authorization of Appropriations; Availability ............................................ 38
Other Sections of Title I of Division D ................................................................................ 38
Section 3102. Native American Health and Wellness Foundation................................... 39
Section 3103. GAO Study and Report on Payments for Contract Health Services .......... 39
Title II of Division D: Improvement of Indian Health Care Provided under the SSA.................. 39
Section 3201. Expansion of Payments under SSA Health Benefit Programs................... 39
Section 3202. Outreach and Enrollment Indians in CHIP and Medicaid ......................... 40
Section 3203. SSA Safe Harbor Proposals for IHPs and UIOs ....................................... 41
Section 3204. SSA Health Benefit Programs Annual Report on Indians Served.............. 41
Section 3205. Interstate Coordination Study .................................................................. 41
Appendixes
Appendix. Acronyms used in the Report.................................................................................... 43
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Contacts
Author Contact Information ...................................................................................................... 44
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Indian Health Care Provisions in H.R. 3962
Introduction
The 111th Congress has devoted considerable effort to health reform that seeks to increase health
insurance coverage for more Americans and help control increasing costs while improving quality
and patient outcomes. H.R. 3962, the Affordable Health Care for America Act, was introduced in
the House of Representatives on October 29, 2009. H.R. 3962 is based on H.R. 3200, America’s
Affordable Health Choices Act of 2009, which was originally introduced on July 14, 2009, and
was reported separately on October 14, 2009, by three House Committees—Education and Labor,
Energy and Commerce, and Ways and Means. One major difference between H.R. 3200 and H.R.
3962 is the addition of Division D, “Indian Health Care Improvement,” which would reenact,
authorize, and amend the Indian Health Care Improvement Act (IHCIA).1 Division D differs from
much of the other divisions of H.R. 3962 in that it targets a specific population group—American
Indians and Alaska Natives, a group that, in general, has lower health status, lower life
expectancy, and higher rates of a number of diseases, including diabetes, than the U.S. population
as a whole. The goal of the division—to improve the health of American Indians and Alaska
Natives—is consistent with the changes proposed in other divisions that also propose to improve
health care access and quality, augment the health care workforce, and increase access to mental
health services.
Overview of Indian Health Care
The Indian Health Service (IHS), an agency in the Department of Health and Human Services
(HHS), provides health care for approximately 1.8 million eligible American Indians/Alaska
Natives through a system of programs and facilities located on or near Indian reservations, and
through contractors in certain urban areas.2 IHS is organized into 12 Areas administered by an
Area Office; Areas, in turn, are further subdivided into service units. IHS may provide services
directly, or Indian tribes (ITs) or tribal organizations (TOs) may operate IHS facilities and
programs themselves through self-determination contracts and self-governance compacts
negotiated with IHS.3 Urban Indian Organizations (UIOs) also provide services using contracts
and grants from IHS.
IHCIA authorizes many specific IHS activities,4 sets out the national policy for health services
administered to Indians, and states the federal goal for the health condition of the IHS service
population, which is to “assure the highest possible health status for Indians and urban Indians.”5
Significantly, IHCIA also authorizes direct collections from Medicare, Medicaid, and other third
party insurers. IHCIA also gives IHS authority to grant funding to urban Indian organizations to
provide health care services to urban Indians, and establishes substance abuse treatment
programs, Indian health professions recruitment programs, and many other programs. The IHCIA
1 P.L. 94-437, act of September 30, 1976, 90 Stat. 1400, as amended; 25 U.S.C. 1601 et seq., and 42 U.S.C. 1395qq,
1396j (and amending other sections).
2 Additional information about IHS can be found in CRS Report RL33022, Indian Health Service: Health Care
Delivery, Status, Funding, and Legislative Issues, by Roger Walke.
3 Authorized by P.L. 93-638, act of January 4, 1975, 88 Stat. 2203, as amended; 25 U.S.C. 450 et seq.
4 CRS Report RL33022, Indian Health Service: Health Care Delivery, Status, Funding, and Legislative Issues, by
Roger Walke.
5 IHCIA, §3(a); 25 U.S.C. 1602(a).
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was last fully reauthorized by the Indian Health Amendments of 1992,6 which extended
authorizations of its appropriations through FY2000. In 2000, all IHCIA appropriations
authorizations were extended through FY2001.7 Congress has continued to appropriate funds for
IHCIA programs since 2001.8 IHCIA reauthorization has been under consideration in Congress
since 1999.9 In the current Congress, IHCIA reauthorization bills were introduced in the House
(H.R. 2708) and the Senate (S. 1790).
Another act, the Snyder Act of 1921,10 provides an additional, but very general, authorization for
Indian health programs. The Snyder Act is a permanent, indefinite authorization for federal Indian
programs, including for “conservation of health.” In 1921, all Indian programs, including health,
were under the management of the Bureau of Indian Affairs (BIA) in the Department of the
Interior (Interior). The Snyder Act was passed in order to authorize all the activities the BIA was
then carrying out. The act’s broad language might be read as authorizing—although not
requiring—nearly any Indian program, including health care, for which Congress enacts
appropriations. The act, however, gives no directions or policies for federal Indian health care.
When Congress transferred Indian health care programs from the BIA to the Public Health
Service (PHS) in the then-Department of Health, Education, and Welfare (predecessor to the
Department Health and Human Services (HHS)) in 1954,11 the Snyder Act’s authorization
accompanied the transfer.
Overview of Report
The Affordable Health Care for America Act (H.R. 3962), as introduced on October 29, 2009,
proposes sweeping reforms of the U.S. health insurance and health care system. H.R. 3962
contains four major divisions: A, B, C, and D. Division A, “Affordable Health Care Choices,”
focuses on reducing the number of uninsured, restructuring the private health insurance market,
setting minimum standards for health benefits, and providing financial assistance to certain
individuals and, in some cases, small employers. Division B, “Medicare and Medicaid
Improvements,” proposes modifications to the largest two health insurance programs to make
them consistent with the changes proposed in Division A and to amend other provisions in
existing federal statute. Division B also introduces a number of technical changes intended to
improve quality of care, reduce federal and state expenditures, and address coverage gaps for both
Medicare and Medicaid. Division C, “Public Health and Workforce Development,” would amend
and expand existing health professions and nursing workforce programs. Division D, “Indian
Health Care Improvement,” would reenact, authorize, and amend the Indian Health Care
Improvement Act (IHCIA). This report does not discuss other Divisions of H.R. 3962; reports on
these divisions can be found at CRS’s website under “Issue in Focus-Health Reform.”12 Proposals
6 P.L. 102-573, act of October 29, 1992, 106 Stat. 4526.
7 Omnibus Indian Advancement Act, P.L. 106-568, §815, act of December 27, 2000, 114 Stat. 2868, 2918.
8 For a discussion of the relationship between appropriations and authorizations, see CRS Report RS20371, Overview
of the Authorization-Appropriations Process, by Bill Heniff Jr.
9 IHCIA reauthorization bills were introduced in the 106th (H.R. 3397 and S. 2526), 107th (S. 212 and H.R. 1662), 108th
(S. 556 and H.R. 2440), 109th (H.R. 5312, S. 1057, S. 3524, and S. 4122), and 110th (H.R. 1328, S. 1200, and S. 2532)
Congresses.
10 P.L. 67-85, act of Nov. 2, 1921 42 Stat. 208, as amended; 25 U.S.C. 13.
11 P.L. 83-568, act of August 5, 1954, 68 Stat. 674, as amended; 42 U.S.C. 2001 et seq.
12 See http://crs.gov/Pages/subissue.aspx?cliid=3746&parentid=13.
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in other divisions of H.R. 3962 may also affect American Indians and Alaska Natives. For
example, Indian tribes may be eligible for grant or contract programs proposed in H.R. 3962 or
may benefit from proposed Medicaid reforms.
This report summarizes the provisions of Division D of H.R. 3962, including those offered as part
of a Manager’s amendment introduced on November 3, 2009.13 The division contains two titles.
Title I contains three sections. Section 3101(a) reenacts, amends, and reauthorizes all eight titles
of IHCIA. Section 3101 (b) and (c) and Sections 3102 and 3103 make changes to Indian
programs, including technical corrections to other federal laws. Title II of Division D contains
five sections (Sections 3201-3205), three of which amend sections of the Social Security Act
(SSA), and none of which amend IHCIA. This report summarizes the major sections of Division
D; for analysis of selected provisions and issues in each title of IHCIA and related SSA programs,
see pages 22-50 of CRS Report RL33022, Indian Health Service: Health Care Delivery, Status,
Funding, and Legislative Issues, by Roger Walke.
The first part of this report covers Title I of Division D, especially Section 3101(a). Section
3101(a) contains IHCIA’s general provisions and its eight titles: (1) Indian health workforce, (2)
health services, (3) health care and sanitation facilities, (4) access to federal reimbursements, (5)
health services for urban Indians, (6) IHS organizational improvements, (7) behavioral health
programs, and (8) miscellaneous. Most authorizations of appropriations are included in the final
section of each IHCIA title. Division D would make each title’s authorizations of appropriations
permanent and indefinite (as noted above, appropriations authorizations in the current IHCIA
expired in FY2000). Sections that include only appropriations authorizations are not summarized
in the discussions below.
This report’s second part covers Title II of Division D. Title II (Sections 3201-3205) includes
provisions related to improving Indian health care provided through federal health programs
authorized in the Social Security Act (SSA)—Medicare, Medicaid, and the Children’s Health
Insurance Program (CHIP). These sections amend the SSA and cross-reference a number of
provisions included in Section 3101(a), especially IHCIA Title IV, which, among other things,
amends the current IHCIA as it relates to these SSA programs. These two titles will be discussed
separately with appropriate cross-references. For Title I of Division D, in most instances, the
discussion of each IHCIA title begins with some background on current law to provide context
for the descriptions of the bill’s provisions.
The Appendix includes a list of acronyms used in this report. The Children’s Health Insurance
Program Reauthorization Act of 200914 renamed the State Children’s Health Insurance Program
and its acronym, SCHIP. The program is now the Children’s Health Insurance Program, or CHIP.
The text of Division D in H.R. 3962 refers to this program as SCHIP, but this report uses the new
acronym, CHIP. The term “Secretary,” as used in this report, means the Secretary of HHS, unless
otherwise indicated. The term “Indian” in this report refers to “Indian” as defined in IHCIA and
maintained in Section 4 below. Under this definition, an Indian is a person who is a member of a
federally recognized tribe, band, nation, or other organized group or community, including any
Alaska Native village or group, or regional or village corporation, as defined in or established
13 See http://docs.house.gov/rules/health/111_hr3962_dingell.pdf for text of the Manager’s amendment.
14 P.L. 111-3, act of Feb. 4, 2009, 123 Stat. 8.
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pursuant to the Alaska Native Claims Settlement Act. 15 The report also includes, in footnotes,
instances where there are potential technical errors in the bill.
This report will be updated to reflect future legislative actions.
Title I of Division D: IHCIA Reauthorization
Federal Indian Health Policy and IHCIA Definitions
Section 3. Declaration of National Indian Health Policy
This section would declare that national policy, in fulfillment of special responsibilities and legal
obligations to Indians, is to assure the highest possible health status for Indians and urban Indians
and to provide all resources necessary to effect the policy; to raise Indian and urban Indian health
status to that set forth in the Healthy People 2010 national health agenda;16 to allow Indians to the
greatest extent possible to set their health care priorities; to increase health professions degrees
awarded to Indians so that the proportion of Indian health professionals is the same as the general
population in each IHS area; to require meaningful consultation with ITs, TOs, and UIOs; and to
fund Indian-operated programs and facilities at the same level as IHS-operated programs and
facilities.
Section 4. Definitions
This section would define 28 terms. It would maintain 12 definitions in current law, amend five
current definitions, delete three terms, and define 11 new terms. The new terms include
“accredited and accessible”, “Assistant Secretary”, “behavioral health,” “California Indians,”
“contract health service,” “Department,” “Indian Health Program,” “reservation,” “telehealth,”
“telemedicine,” and “Tribal Health Program.”
The report uses the following terms: “Indian Health Program” (IHP), which is defined as any
health program administered by the IHS or by an IT or TO under either the Indian Self-
Determination and Education Assistance Act, as amended (ISDEAA),17 or the Buy Indian Act;18
and “Tribal Health Program” (THP), which is defined as any tribe or tribal organization operating
a health program under ISDEAA. THPs are included within the term IHP.
15 P.L. 92-203, act of Dec. 18, 1971, 85 Stat. 688, as amended; 43 U.S.C. 1601 et seq.
16 See http://healthypeople.gov/.
17 P.L. 93-638, act of Jan. 4, 1975, 88 Stat. 2203, as amended; 25 U.S.C. 450 et seq.
18 25 U.S.C. 47
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Indian Health Workforce19
IHCIA Title I in Section 3101(a) includes provisions related to personnel recruitment,
scholarships, and other educational programs that would address the Indian health workforce. IHS
has high vacancy rates in many of its health professions––over 20% for physicians, dentists, and
nurses, for instance, as of December 2008.20 The purpose of IHCIA Title I is to increase the
number, and also enhance the skills, of Indian and non-Indian health professionals and other
health personnel in the IHS. To do this, the title would authorize scholarships for preparatory and
professional schools. Compared with current law, H.R. 3962 would add UIO programs and
employees, where possible, as eligible for workforce programs. It would also expand the right to
a “retention bonus” to all health professionals employed in or assigned to IHP or UIO programs.
Section 102. Health Professions Recruitment Program for Indians
This section would authorize grants to THPs or UIOs, and public and nonprofit entities for
recruitment programs, to include identifying Indians with potential for entering health
professions, publicizing funding sources, and establishing programs to facilitate enrollment in
health professions courses of study. This section also includes requirements for funding
applications, and the amount of funding, in addition to outlining the eligibility for these programs,
and establishing a three year grant period.
Section 103. Health Professions Preparatory Scholarship Program for Indians
This section would authorize scholarships to Indians for compensatory pre-professional education
as well as undergraduate education leading to a baccalaureate degree in a preparatory field for a
health profession. The pre-professional scholarships would be awarded for up to two years on a
full-time basis, and undergraduate scholarships would be awarded for up to four years (with an
extension of up to two years). This section also would specify the expenses covered by the
scholarship and would specify that scholarships cannot be denied on scholastic achievement if the
applicant has already been admitted or maintains good standing at an accredited institution, or
denied because of the applicant’s eligibility for assistance under other federal programs.
Section 104. Indian Health Professions Scholarships
This section would authorize scholarships to Indians enrolled full- or part-time in accredited
schools pursuing courses of study in the health professions, in accordance with Section 338A of
the Public Health Service Act21 (PHSA). Scholarship recipients would be obligated to serve at an
IHS, THP, or urban Indian health project (UIHP), or in a private practice located in a health
professional shortage area that has a substantial number of Indians, for the greater of either one
19 Division C of H.R. 3962 includes provisions that would create new or reauthorize a number of existing workforce
and public health programs, in a number of cases IT and TO may be eligible for these programs. See CRS Report
R40892, Public Health, Workforce, Quality, and Related Provisions in H.R. 3962, coordinated by C. Stephen Redhead.
20 U.S. Department of Health and Human Services, Public Health Service, Indian Health Service, Indian Health
Service: Fiscal Year 2010 Justification of Estimates for Appropriations Committees (Rockville, MD: HHS/PHS/IHS,
2009), pp. CJ-147 to CJ-148; http://www.ihs.gov/NonMedicalPrograms/BudgetFormulation/documents/documents/
IHS_CJ_2010_Final_Submission.pdf
21 42 U.S.C. 254l.
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year for each scholarship year or two years. The section would also authorize the Secretary to
allocate scholarships among health professions based on health services needs, specify guidelines
for fulfilling the service obligation in private practice or through teaching, set sanctions for failure
to complete service obligations, and permit the Secretary to waive the service obligation under
certain circumstances.
Section 105. American Indians into Psychology Program
This section would authorize the Secretary, acting through the IHS director, to establish a grant
program to award grants of not more than $300,000 to each of nine colleges and universities for
developing and maintaining Indian psychology career recruitment programs. The sections would
require that one grant be awarded to the University of North Dakota to establish a “Quentin N.
Burdick American Indians into Psychology Program.” The section would also require that grants
be awarded to locations throughout the United States to maximize their availability to Indian
students, including grants at new locations. In addition, the section would require the Secretary to
issue regulations for competitive funding, and would specify conditions of the grants, including
recipients’ service obligations. The section would authorize an appropriation of such sums as may
be necessary to carry out this section.
Section 106. Scholarship Programs for Indian Tribes
This section would require the Secretary, acting through IHS, to make matching grants to ITs or
TOs for scholarships to educate Indians to serve as health professionals in Indian communities.
The section would require that entities receiving grants match 20% of the funds. The section
would specify (1) the requirements for receiving such funds, the course of study, contract
conditions, and specific parameters for a breach of contract; (2) that individuals receiving
scholarships would not be permitted to discriminate against patients who receive assistance
through the Medicare, Medicaid, and CHIP programs; and (3) the conditions of continuance of
funding. Recipients would be required to use the scholarship for tuition and reasonable education
or living expenses, to meet their health professions’ licensing and educational requirements, and
to fulfill service obligations. Recipients may serve in another IHS Area if the tribe and IHS
approve and if services are not diminished in the contracting tribe’s Area.
Section 107. Indian Health Service Extern Programs
This section would require that recipients of scholarships under IHCIA Sections 104 or 106
receive preference for IHS employment and authorized employment with IHS, tribal, or urban
Indian health programs or with other HHS agencies, during non-academic parts of a year, without
regard to competitive or agency personnel limitations. The section would specify that such
employment would not be counted towards any active duty service obligation. The section would
also authorize an extern program for enrollees in health professions recruitment programs under
IHCA Section 102(a), including high school programs, and would specify the timing and length
of such employment.
Section 108. Continuing Education Allowances
This section would authorize the Secretary to provide programs or allowances to encourage
specified health professionals and scholarship and stipend recipients under IHCIA Sections 104,
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105, 106, and 115 to join or continue in IHS and THPs, and to work in rural or remote areas
where significant numbers of Indians reside. These programs or allowances may be used to help
individuals to transition into IHPs, including licensing and board or certification examination
assistance and technical assistance in fulfilling service obligations. The section would also
authorize programs and allowances for IHS and tribal health professionals to take leave of their
duty stations for a period of time each year for specified continuing professional education.
Section 109. Community Health Representative Program
This section would require the Secretary to establish through IHS, IT, and TOs a program of
health paraprofessionals, called Community Health Representatives (CHRs), to provide health
care, health promotion, and disease prevention services in Indian communities. The section would
require the Secretary to establish training and continuing education for CHRs, provide
supervision and evaluation systems, and promote traditional tribal health care practices as
consistent with IHS standards for health care.
Section 110. Indian Health Service Loan Repayment Program
This section would require the Secretary to establish a loan repayment program for health
professionals who contract to work for a specified time for, or are already employed by, IHPs or
UIHPs. The section would specify the individuals eligible for the program and the program’s
application, selection, and notification processes. It would further specify that the program would
give first priority to Indian applicants. The loan repayment program would include payment of
principal, interest, and related expenses of school loans up to $35,000 for each year of obligated
service and, in addition to this payment, may include an amount to cover tax liability incurred for
this payment. This section also includes a number of other program requirements, such as those
related to assigning individuals and recruitment programs, and it includes a required annual report
to Congress.
Section 111. Scholarship and Loan Repayment Recovery Fund
This section would establish, within the Department of the Treasury, an Indian Health Scholarship
and Loan Repayment Recovery Fund (Fund), consisting of amounts that may be collected from
contract breaches under IHCIA Sections 104, 106, and 110, plus any appropriation to the Fund
and interest. The section authorizes Fund payments to THPs with health professional needs
resulting from breaches of contracts under the three programs, and allows THPs receiving such
payments to use them for scholarships and recruitment or employment of health professionals.
The section would also require the Secretary of the Treasury to invest any amounts in the Funds
that the HHS Secretary determines are not needed to meet current withdrawals.
Section 113. Indian Recruitment and Retention Program
This section would require the Secretary to fund, on a competitive basis, demonstration projects
to enable IHPs and UIOs to recruit, place, and retain health professionals to meet their staffing
needs. The section would specify that any IHP or UIO may apply for these funds, and limits
funding for a project to three years.
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Section 114. Advanced Training and Research
This section would require the Secretary to establish a program to enable health professionals
who have worked for an IHS, THP, or UIHP for a substantial period of time to pursue advanced
training or research in areas of study where the Secretary determines a need exists. The section
would obligate participants to work for an equivalent period for IHS or a tribal or urban health
program, make participants failing to complete such service liable to the United States for the
remaining service period, and require equal opportunity to participate in the program for ITs and
TOs.
Section 115. Quentin N. Burdick American Indians into Nursing Program
This section would require the Secretary to make grants to nursing schools, tribally-controlled
community and vocational colleges, and nurse-midwife and advanced practice nurse programs to
increase the number of nurses serving Indians, through scholarships, recruitment, continuing
education, or other programs encouraging nursing services to Indians. The section would specify
the criteria that the Secretary would be required to use when making grant awards, and would
require that one grant be for the establishment of the “Quentin N. Burdick American Indians into
Nursing Program” at the University of North Dakota. The section would specify the uses of
grants and the required service obligations for individuals who receive a scholarship under this
section. The section would also require that applicants show a connection to a health facility
primarily serving Indians.
Section 116. Tribal Cultural Orientation
This section would require the Secretary to establish a mandatory training program, for
appropriate IHS employees serving tribes in each IHS Area, in the history and culture of the tribes
they serve and the tribes’ relationship to IHS. The section would require the Secretary, to the
extent feasible, to develop the program in consultation with the affected ITs , TOs, or UIOs, to
implement the program, which includes instruction in Native American studies and traditional
health care practices, through tribal community and vocational colleges.
Section 117. INMED Program
This section would authorize the Secretary to provide grants to colleges and universities to
maintain and expand the Indian health careers recruitment program (“Indians Into Medicine
Program,” or “INMED”), and would require that one of the grants go to the “Quentin N. Burdick
Indian Health Programs” at the University of North Dakota. The section would also specify the
requirements and regulations for the grant program.
Section 118. Health Training Programs of Community Colleges
This section would require the Secretary to award grants to accredited and accessible community
colleges to assist in establishing health profession education programs leading to a degree or
diploma for individuals desiring to practice on or near an Indian reservation or in an IHP. The
section would set the maximum first year grant at $250,000. The section would also require the
Secretary to award grants to community colleges that already have such programs, and to provide
technical assistance and qualified IHS personnel to teach courses. The section would set
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eligibility requirements for colleges and would give priority to tribally-controlled colleges in IHS
Areas if other requirements in the section are met, and would require grantees to provide Indian
preference for program participants and advanced training for health professionals.
Section 119. Retention Bonus
This section would authorize the Secretary to pay retention bonuses to any health professional
employed by an IHS, TO, or UIO, in needed positions for which recruitment is difficult, who
agree to continue their current employment with IHS, a THP, or UIHP for not less than one year.
The health professional must have completed two years of employment in an IHS, IHP, or UIO,
or any service obligation from federal scholarships or loan repayment programs. Retention
bonuses may be higher for multiple years but may not exceed an annual rate of $25,000. The
section would require that the health professional refund the bonus if the term of service is not
completed, unless the default is not the fault of the individual.
Section 120. Nursing Residency Program
This section would require the Secretary to establish a program to enable Indians who are
licensed practical nurses, licensed vocational nurses, and registered nurses working for an IHP or
UIO for at least one year to pursue advanced training in a residency program. The program shall
include a combination of education and work study leading to either an associate or bachelor’s
degree for specified nursing disciplines or to any advanced degree or certification in nursing and
public health. The section would require that participants incur a service obligation time period
that is twice the period of time in the program for professional nurses and the same as the period
of time in the program for nonprofessional nurses.
Section 121. Community Health Aide Program
This section would require the Secretary, under authority of the Snyder Act, to develop and
operate a Community Health Aide Program (CHAP) in Alaska, under which IHS trains Alaska
Natives to provide health care, health promotion, and disease prevention in rural Alaska Native
villages. The section would require the Secretary to provide, in a specified manner, a high
standard of training to community health aides, to establish a CHAP certification board, and to
provide continuing education, close supervision, and a system to review and evaluate CHAP
work. The section would prohibit a CHAP dental health aide therapist from performing certain
pulpal therapy or extractions without a determination of a medical emergency by a licensed
dentist and from performing any other oral or jaw surgeries except for uncomplicated extractions.
The section would also authorize the expansion of CHAP, except for the dental health aide
therapist program, into a national program, but would require that the expansion not reduce
Alaska CHAP funding. The section would require the Secretary to establish a neutral review
panel to study the CHAP dental health aide therapist program to ensure that the quality of care is
adequate and appropriate. The section would also specify panel membership, and the factors of
the study, and would require consultation with Alaska tribal organizations and a report to
Congress.
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Section 122. Tribal Health Program Administration
This section would require the Secretary to provide training to Indians in the administration and
planning of THPs.
Section 123. Health Professional Chronic Shortage Demonstration Programs
This section would authorize the Secretary to fund demonstration programs for THPs to address
chronic shortages in health professionals. The section would specify the purposes of the
demonstration programs, and would require that the programs incorporate an advisory board
composed of representatives from tribes and Indian communities served by the program.
Section 124. National Health Service Corps
This section would prohibit the Secretary from removing a member of the National Health
Service Corps22 (NHSC) from an IHS, IHP, or UIO, or withdrawing funding to support such
member, unless the Secretary ensures that Indians will experience no reduction in services. The
section would authorize that, at the IHP’s request, the services of NHSC personnel may be limited
to only the persons eligible for services from that IHP.
Section 125. Substance Abuse Counselor Educational Demonstration Programs
This section would authorize the Secretary to enter into contracts with or make grants to
accredited and accessible tribal community colleges, tribal vocational colleges, and eligible
community colleges to establish demonstration programs developing educational curricula for
substance abuse counseling. The section would limit grants to three years, with a two year
renewal, and would require the Secretary (in consultation with tribes, tribal and community
colleges, and eligible community colleges) to issue criteria for approval of applications. The
section would also require the Secretary to provide technical and other assistance to grant
recipients, and submit an annual report to the President for inclusion in the annual report to
Congress. The section would define the term “educational curriculum.”
Section 126. Behavioral Health Training and Community Education Programs
This section would require the Secretary and the Secretary of the Interior, in consultation with IT
and TOs, to conduct a study and compile a list of specified types of staff positions within the BIA,
IHS, ITs, TOs, and UIOs whose qualifications should include training in the identification,
prevention, education, referral, or treatment of mental illness, dysfunction, or self-destructive
behavior. The appropriate Secretary would be required to provide training criteria appropriate for
each type of position and to ensure that this training is provided. The Secretary would be
required, upon request by a IT, TO, or UIO, to develop and implement a program of community
education on mental illness, or assist the requester with doing so. The section would also require
the Secretary to provide technical assistance for obtaining and developing community education
22 For more information on the this program, see CRS Report R40533, Health Care Workforce: National Health
Service Corps, by Bernice Reyes-Akinbileje. Proposed changes to this program in H.R. 3962 can be found in CRS
Report R40892, Public Health, Workforce, Quality, and Related Provisions in H.R. 3962, coordinated by C. Stephen
Redhead.
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materials. Within 90 days of enactment, the Secretary would be required to develop a plan, to be
implemented under the Snyder Act, to increase behavioral health services by at least 500 staff
positions within five years, with at least 200 of such positions devoted to child, adolescent, and
family services.
Section 127. Exemption from Payment of Certain Fees
This section would exempt employees of a THP or UIO from the payment of licensing,
registration, and other fees imposed by a federal agency, to the same extent that PHS
Commissioned Corps officers or other IHS employees are exempt from the fees.
Health Services
IHCIA Title II in Section 3101(a) would authorize a number of specific non-behavioral-health
programs and activities, including prevention activities, diabetes and cancer programs, Indian
men’s health, Indian school health education programs, research and epidemiological centers, and
a fund for the elimination of funding inequities among health care programs. The title would also
define the contract health service (CHS) delivery areas in several states. CHS refers to services
that IHS, ITs, or TOs may purchase, through contract, from private providers in instances where
the THP cannot provide the needed care.
Section 201. Indian Health Care Improvement Fund
This section would authorize the use of funds, designated as the “Indian Health Care
Improvement Fund” (IHCIF), to eliminate tribes’ deficiencies in health status and resource (as
defined in the section), eliminate backlogs in provision of health care to Indians, meet health
needs efficiently and equitably, eliminate inequities in funding for both direct care and CHS, and
augment the ability of IHS to meet 10 specified health service responsibilities. The Secretary
would be authorized to expend IHCIF funds either directly or through contracts or compacts
under ISDEAA. The section would prohibit using funds appropriated under this section to offset
funds appropriated under other laws, allow IHCIF allocation among service units and THPs, and
require the Secretary to determine (with the participation of affected tribes and tribal
organizations) the apportionment of funds among service units, tribes, and tribal organizations for
the specified health service responsibilities. The section would make THPs equally eligible for
funds with IHS programs and would require that appropriations under this section be included in
the base budget of the IHS for subsequent fiscal years. The section would also require a report to
Congress three years after enactment on the current health status and resource deficiencies for
each tribe or service unit, and would specify the data to be included in the report. In addition, the
section would specify that nothing in the section is intended to diminish the primary
responsibility of the IHS to eliminate backlogs in unmet health care or to discourage additional
efforts by IHS to achieve parity among tribes.
Section 202. Health Promotion and Disease Prevention Services
This section would make a congressional finding that health promotion and disease prevention
activities improve the health and well-being of the Indian population while reducing health care
expenses. It would require the Secretary to provide such services to Indians in order to meet the
act’s health status objectives, and would require the Secretary, after receiving input from THPs, to
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submit to the President an evaluation statement of the resources required to undertake these health
promotion and disease prevention activities. This evaluation statement would be included in
annual reports to Congress.
Section 203. Diabetes Prevention, Treatment, and Control
This section would require the Secretary to determine the incidence of diabetes and its
complications among Indians and, based on the incidence determined, what actions IHS service
units would need to take to prevent, treat, and control the disease, including effective ongoing
monitoring. The Secretary would be required to screen Indians for diabetes and for conditions
that indicate a high risk for diabetes; it would require that such screenings be medically indicated
and conducted with informed consent. The section would also permit screening through Internet-
based programs, and would require the Secretary to establish a cost-effective approach to ensure
ongoing monitoring of diabetes indicators. In addition, the section would require the Secretary to
maintain existing model diabetes projects and authorize the Secretary to provide dialysis
programs for IHS, ITs, and TOs, including equipment and staffing. The Secretary would be
required to consult with the ITs and TOs in each IHS area on diabetes programs, establish
diabetes patient registries in each IHS Area Office, and ensure that the data collected are
disseminated to other Area Offices. The section would also authorize diabetes control officers in
each IHS Area Office.
Section 204. Shared Services for Long-Term Care
This section would authorize the Secretary to provide, directly or through ISDEAA contracts or
compacts with THPs, long-term care and health care services associated with long-term care at
any long-term care or related facility owned or operated by a THP directly or under ISDEAA.
The section would require that the agreements provide for sharing staff and other services
between an IHS facility and the contracting IT’s or TO’s facility. The section would authorize
such contracts to allow delegation to the contractors of necessary supervision over IHS
employees, and would allow ITs and TOs to construct, renovate, or expand nursing facilities. The
section would also specify certain terms of the agreement, including funding allocations, and
would also specify that any nursing facility funded under this section must meet the requirements
for such facilities under Medicare statute. The section would also require the Secretary to provide
necessary technical and other assistance to tribal applicants, and to encourage the use of existing
underused facilities or allow the use of swing beds, for long-term or similar care.
Section 205. Health Services Research
This section would authorize funding for clinical and nonclinical research to further the
performance of IHPs’ responsibilities. The section would require the Secretary to coordinate HHS
research resources and activities to address IHP research needs, to the maximum extent practical.
The section would also require that THPs have equal opportunity to compete for these research
funds and would require the Secretary to evaluate the impact of the research conducted under this
section and disseminate research findings to THPs as appropriate.
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Section 206. Mammography and Other Cancer Screening
This section would require the Secretary to provide for screening mammography for Indian
women, at a frequency determined appropriate under accepted national standards and under terms
and conditions consistent with standards established by the Secretary under the SSA, to ensure
the safety and accuracy of the mammography. The section also would require the Secretary to
provide certain other cancer screening that complies with the recommendations of the United
States Preventive Services Task Force (USPSTF) on specified factors.
Section 207. Patient Travel Costs
This section would authorize the Secretary, through IHS, to provide funds for specified patient
travel costs associated with receiving IHS-funded health care services, including emergency air
transport and non-emergency air transport where ground transport is not feasible; transportation
by ambulance, specially equipped vehicle, or private vehicle where no other transportation is
available; or other means required when air or motor vehicle transport is not available. The
section would also authorize funding for qualified escorts, as defined in the section.
Section 208. Epidemiology Centers
This section would require the Secretary to establish an epidemiology center in each IHS Area to
carry out seven specified functions, in consultation with ITs and tribal and urban Indian
communities. An epidemiology center would be subject to ISDEAA. The section would require
that the Director of the Centers for Disease Control and Prevention (CDC) provide technical
assistance to these epidemiology centers. The section would also authorize the Secretary to make
grants to tribes, tribal and urban Indian organizations, and eligible intertribal consortia (as
defined) to operate an epidemiology center and to conduct epidemiological studies of Indian
communities, and would specify the criteria for applicants and the uses of such grants. The
section would further require that epidemiology centers operated under such grants be treated as
public health authorities for purposes of the Health Insurance Portability and Accountability Act23
(HIPAA). In addition, the section would require the Secretary to grant such centers access to and
use of data, data sets, monitoring systems, delivery systems, and other protected health
information in the Secretary’s possession, and would specify that such centers’ activities would be
required to be, for purposes of HIPPAA, for research or disease prevention and control.
Section 209. Comprehensive School Health Education Programs
This section would authorize the Secretary to provide grants to ITs and TOs to develop
comprehensive school health education programs for children from pre-school through grade 12
in schools for the benefit of Indian children. The section would specify the purposes for which
grant funds may be used and would require the Secretary to provide technical assistance to ITs
and TOs in developing and disseminating comprehensive health education plans, materials, and
information, and, in consultation with these groups, to establish criteria for review and approval
of grant applications. The section also would require the Secretary of the Interior, in consultation
with the HHS Secretary, to develop similar school health education programs in BIA-funded
23 P.L. 104-191, act of Aug. 21, 1996, 110 Stat. 1936, as amended.
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schools.24 In addition, the section would specify the subjects the programs must include, and it
directs the Interior Secretary to provide teacher training, ensure coordination with community
programs, and encourage healthy, tobacco-free school environments.
Section 210. Indian Youth Program
This section would authorize the Secretary to make grants to ITs, TOs, and UIOs for innovative
mental and physical disease prevention and health promotion and treatment programs for Indian
and urban Indian preadolescent and adolescent youths. The section would specify the criteria to
review and approve applications, and the allowable and prohibited uses of the grants, and would
require the Secretary to disseminate information to ITs, TOs, and UIOs regarding models for
delivery of comprehensive health care services to Indian youth, encourage the implementation of
these models, and provide technical assistance upon request. The section would also prohibit
funds provided under this section to be used for Indian youth services described in IHCIA Section
707.
Section 211. Projects Related to Communicable and Infectious Diseases
This section would authorize the Secretary to make grants to ITs, TOs, and UIOs for projects to
prevent, control, and eliminate communicable and infectious diseases, provide public information
and education on such diseases, provide education and skills improvement activities on such
diseases for health professionals, and establish demonstration projects for the screening,
treatment, and prevention of the hepatitis C virus. Grant recipients would be encouraged to
coordinate their activities with the CDC and state and local health agencies. The section would
also authorize the Secretary to provide technical assistance, upon request, and would require the
Secretary to make a biennial report to Congress.
Section 212. Other Authority for Provision of Services
This section would authorize the Secretary to provide funding, through programs and services of
IHS, ITs, and TOs, for health-care-related services and programs (not otherwise specified in the
act) for hospice care, assisted living, long-term care, and home- and community-based services.
This section would also define these terms. “Assisted living services” would be defined as any
service provided by an assisted living facility (as defined in Section 232 of the National Housing
Act) although the facility would be exempt from having to obtain a license, but would be required
to meet all applicable standards for licensure. “Home- and community-based services” would be
defined as certain services listed in SSA Section 1929 that are or will be provided in accordance
with applicable standards. “Hospice care” would be defined as certain services listed in SSA
Section 1861 and such other services as an IT or TO determines are necessary and appropriate to
provide in furtherance of the hospice care. “Long-term care services” would be defined to be the
same as “qualified long-term care services” in Section 7702B of the Internal Revenue Code of
1986 (IRC). The section would specify the criteria by which individuals would be eligible for
long-term care. The section would also authorize funding, through IHS, tribes, and tribal
organizations, for “convenient care services” pursuant to IHCIA Section 306.25
24 The BIA’s educational programs were transferred to a new agency, the Bureau of Indian Education (BIE), in 2006.
25 This section would authorize convenient care as defined in IHCIA Section 306; however, this term is neither
(continued...)
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Section 213. Indian Women’s Health Care
This section would require the Secretary, acting through IHS, ITs, TOs, and UIOs, to monitor and
improve the quality of Indian women’s health care delivered through programs administered by
IHS.
Section 214. Environmental and Nuclear Health Hazards
This section would require the Secretary and IHS, in conjunction with other federal agencies and
in consultation with concerned tribes and organizations, to conduct studies on trends in health
hazards to Indian miners and Indians on or near reservations and in Indian communities as a
result of environmental hazards which may result in chronic or life threatening health problems.
The section would specify the subjects of the studies, and would require the Secretary and IHS,
upon completion of the studies, to develop health care plans to address the health problems
studied, including diagnosis, treatment, preventive care, testing, and education. The section would
require the Secretary to submit the study to Congress 18 months after enactment and, no later
than one year after the study, submit to Congress a report containing the health care plans, with
recommendations for implementation. The section would also establish an Intergovernmental
Task Force, chaired by the Secretary, to identify nuclear resource development or other
environmental hazards and take corrective action. The section would require IHPs to provide
medical care to IHS-eligible Indians who suffer from work-related conditions as a result of
employment in uranium mines or mills on or near any other environmental hazard, would
authorize reimbursement from the mine or mill operator or other responsible entity who would be
responsible for the expense of such care.
Section 217. California Contract Health Services Program
This section would authorize the Secretary to fund a program using an intertribal consortium as a
CHS intermediary to improve the accessibility of health services to California Indians. The
section would require the Secretary to enter an agreement with an intertribal consortium to
reimburse the intertribal consortium for costs incurred including limited administrative expenses
while serving as a CHS intermediary. This section references the definitions of California Indians
in Section 805 and the California CHS delivery area in Section 218.26 This section also would
specify that no payment may be made for treatment under this section to the extent payment may
be made under the Catastrophic Health Emergency Fund (as described below) or from amounts
appropriated or otherwise made available to the California CHS delivery area. This section would
also establish an Advisory Board to advise the intertribal consortium in carrying out this section,
to be comprised of representatives from not less than eight THPs serving California Indians
covered under this section and at least one-half of whom are not affiliated with the intertribal
consortium.
(...continued)
mentioned nor defined in IHCIA Section 306.
26 This section references Section 219 for the California CHS area, the correct reference is Section 218.
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Section 221. Licensing
This section would require that licensed health care professionals employed by a THP would be
exempt from state licensing requirements while employed at a THP providing services under an
ISDEAA contract or compact.
Section 222. Notification of Provision of Emergency Contract Health Services
This section would allow 30 days (as a condition of payment) for notifying IHS of any emergency
medical care or services received by an elderly or disabled Indian from a non-IHS provider or in a
non-IHS facility under the authority of this act.
Section 223. Prompt Action on Payment of Claims
This section would require IHS to respond to notification of a claim by a CHS provider within
five working days of receipt of the notification, with either an individual purchase order or a
claim denial. The section also provides that if IHS fails to respond within the required time, IHS
would be required to accept the claim as valid. The section would require IHS to pay a valid CHS
claim within 30 days after completion of the claim.
Section 224. Liability for Payment
This section would exempt a patient who receives IHS-authorized CHS from being held liable for
any charges or costs associated with those authorized services. The section would also require the
Secretary to notify the CHS provider and the patient who receives the services that the patient is
not liable, within five business days of receipt of a notification of a claim by the provider. The
section prohibits the CHS provider from recourse against the patient for payment if the notice has
been received or if the claim has been deemed accepted under IHCIA Section 224.27
Section 225. Office of Indian Men’s Health
This section would authorize the Secretary to establish the Office of Indian Men’s Health in IHS,
headed by a Director appointed by the Secretary, to coordinate and promote the health status of
Indian men. The section would require the Secretary to submit a report to Congress within two
years of enactment describing any activities and findings of the Director.
Section 226. Catastrophic Health Emergency Fund
This section would establish the Catastrophic Health Emergency Fund (CHEF), to be
administered by the Secretary through the IHS central office, to meet extraordinary medical costs
associated with the treatment of victims of disasters or catastrophic illnesses. The section would
specify the uses, administration, and regulations of this fund. It would also specify that CHEF
would consist of appropriations and third-party reimbursements to which IHS is entitled for
treatments paid for by CHEF, and would require that no part of the CHEF or the administration
thereof be subject to contract or grant. It also would require that CHEF not be apportioned on an
27 The bill specifies Section 224; however, it is likely referring to Section 223.
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Area Office, Service Unit, or any other basis. The section would also prohibit funds appropriated
to CHEF from being used to offset or limit other IHS appropriations and requires that all
reimbursements to which IHS 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, be deposited
into CHEF.
Health Care and Sanitation Facilities
IHCIA Title III of Section 3101(a) covers health care and sanitation facilities. IHS funds the
construction, equipping, and maintenance of hospitals, health centers, clinics, and other health
care delivery facilities, for facilities operated by IHS and tribes. IHS also funds the construction
of water supply and sewage facilities and solid waste disposal systems, and provides technical
assistance for the operation and maintenance of such facilities. This title would set new
requirements for closure of IHS-operated health care facilities, authorize a feasibility study for a
new health-facility construction loan fund for ITs and TOs, and allow IHS to accept funding for
health care facility construction from federal, state, and non-governmental sources.
Section 301. Consultation; Construction and Renovation of Facilities; Reports
This section would require that the Secretary, prior to expending or firmly committing to expend
funds for planning, designing, constructing, or renovating facilities, consult with affected ITs and
ensure that the facility meets the construction standards of any accrediting body recognized by the
Secretary for the Medicare, Medicaid and CHIP programs. The section would prohibit closure of
any IHS hospital or outpatient health care facility unless the Secretary has submitted to Congress
not less than one year and not more than two years before the date of the proposed closure, an
evaluation of the impact of the proposed closure, completed not more than two years before such
submission, with specified information; temporary closures for medical, environmental, or
construction safety reasons are exempted from this requirement. The section requires that the
Secretary maintain a health care facility priority system that is developed in consultation with ITs
and TOs that prioritizes tribal needs, includes the methodology for prioritization, and allows the
nomination of new projects at least once every three years, and may include the top 10 priority
facilities for five specified types of facilities as well as other facilities or needs as IHPs may
identify. The section would prohibit a project’s priority in effect at enactment from being affected
by a new facility priority system if the project meets specified criteria and was identified in the
FY2008 IHS budget justification as in the top 10 for five specified types of facilities.28
The section would also authorize the Secretary to establish a Facilities Appropriations Advisory
Board and a Facilities Needs Assessment Workgroup, and would require the Secretary to submit
to specified committees of Congress an initial report with a national ranked list of all IHPs health
care facilities needs developed for the board and workgroup, and would require the Secretary to
update the report every five years beginning in 2011. The section would also require the Secretary
to submit to the President, for inclusion in reports to Congress, an annual report describing the
new health care facility priority system and its methodology and listing top 10 facilities for 5
specified types of facilities with justifications and projected costs; the Secretary would be
required to prepare the annual report in consultation with ITs, TOs, and UIOs and would be
28 The five types of facilities are: inpatient health care facilities, outpatient health care facilities, specialized health care
facilities (e.g., long-term care facilities), wellness centers, and staff quarters.
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required to review the ITs’ and TOs’ total unmet facility needs. The section would also require the
U.S. Government Accountability Office (GAO) to study the methodologies used by IHS in
developing the health care facility priority system and making facility needs assessments, and
report to specified committees of Congress and the Secretary. The section would require the
Secretary to cooperate with ITs, TOs, and UIOs in developing innovative approaches to address
unmet facility needs. The section would also make facility funds appropriated under the Snyder
Act subject to ISDEAA.
Section 302. Sanitation Facilities
This section would provide Congressional findings on water and sanitary systems and Indian
communities; would affirm IHS’s primary responsibility and authority to provide sanitation
facilities and services; would authorize financial and technical assistance to IT, TO, and Indian
communities for utility organizations to operate sanitation facilities; and would authorize priority
funding for operation or maintenance assistance (including emergency repairs) to avoid imminent
health threats or protect the investment in health benefits gained through the sanitation facilities.
The section would authorize the Secretary of Housing and Urban Development (HUD) to transfer
funds appropriated under the Native American Housing and Self-Determination Act29 to the HHS
Secretary, but would prohibit the use of IHS funding for new homes constructed using HUD
funds (unless authorized when appropriated).
The section would authorize the Secretary to accept sanitation facility funds from a variety of
sources, would authorize the Secretary to use Indian Sanitation Facilities Act funding to fund
tribes’ federal loans or meet matching or cost participation requirements to construct sanitation
facilities; would require the Secretary to enter into federal interagency agreements for financial
assistance for sanitation facilities; and would require the Secretary to establish standards, by
regulation, for the planning, design and construction of sanitation facilities. In addition, the
section would require that the financial and technical capability of an IT, TO, or Indian
community to safely operate and maintain a sanitation facility would not be a prerequisite to the
provision or construction of sanitation facilities by the Secretary. The section would assign ITs
primary responsibility for collecting user fees and other funding to operate and manage sanitation
facilities, but would authorize the Secretary to assist the operating tribe or organization when a
facility is threatened with imminent failure. The section would also require that THPs be equally
eligible with IHS for funds appropriated under this section or to provide sanitation facilities. The
section would also require the Secretary submit to the President, for inclusion in reports to
Congress, an annual report (developed in consultation with IT, TOs, HUD, and tribally-designated
housing entities) on the current IHS sanitation facility priority system, the level of sanitation
deficiency (as defined in the section) for each sanitation facilities project, the funding necessary
to raise all ITs and communities to the highest sanitation levels, and a 10-year plan to provide
sanitation facilities to existing, renovated, and new Indian homes and to Indian communities. The
Secretary would be authorized to provide to ITs, TOs, and Indian communities the federal share
of the costs of operating and maintaining the facilities described under the 10-year plan. The
section would define the term “Indian community,” and defines “sanitation facilities” to include
safe and adequate water supply systems, sanitary sewage and solid waste disposal systems, and
all related equipment and support infrastructure.
29 P.L. 104-330, act of Oct. 26, 1996, 110 Stat. 4017, as amended; 25 U.S.C., Chap. 43 and other sections, and various
sections in Titles 12 and 42, U.S. Code.
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Section 303. Preference to Indians and Indian Firms
This section would authorize the Secretary to use the Buy Indian Act to give Indians and Indian
firms (as defined in the section) preference in the construction of IHS health care and sanitation
facilities pursuant to IHCIA Sections 301 and 302 discussed above. This section would permit
such preference unless the Secretary finds that the contracted project, under specified factors,
would not be satisfactory or cannot be properly completed or maintained. The section would
require the Secretary to assure that pay rates for construction or renovation of facilities under
IHCIA Title III are not less than the prevailing local wage rates as determined in accordance with
the Davis-Bacon Act,30 and direct that contracts for construction or renovation of facilities under
IHCIA must also comply with the Davis-Bacon Act.
Section 304. Expenditure of Non-Service Funds for Renovation
This section would authorize the Secretary to accept any major renovation, expansions, or
modernization by an IT or TO of any IHS facility or any health facility operated under ISDEAA.
The section would set criteria for accepting such renovation, expansion, or modernization. In
addition, the section would require the Secretary to maintain a separate priority list for such
facilities’ needs for increased operating expenses, personnel, and equipment and develop and
revise the methodology for establishing the priority list annually in consultation with IT and TO.
The Secretary would also be required to include the priority list in a report submitted to the
President for inclusion in annual reports to Congress. The section would require ITs and TOs to
provide the Secretary with staffing, equipment, and other costs of facility expansions. The section
would also authorize an IT that completed such a renovation or modernization to recover the
prorated value of the facility if the facility ceases to be used as an IHS facility within 20 years
after completion.
Section 305. Funding for Small Ambulatory Care Facilities
This section would require the Secretary to make grants to ITs and TOs for THPs to construct,
expand, or modernize small ambulatory care facilities. The section would establish criteria for
eligible facilities, including providing at least 150 patient visits annually in a service area with at
least 1,500 eligible Indians (unless the facilities are on an island or are without road access to an
inpatient hospital). The section would also permit a portion of funds to be used for debt reduction
for ITs or TOs that built, expanded, or modernized facilities. For all grants awarded, the section
would require that funding be used for the portion of costs which benefits the eligible population.
The section would require that grants be approved under regulations, would require certain
assurances of grant applicants, would assign grant priority to applicants demonstrating need, and
would authorize the Secretary to use peer review panels to evaluate applications. The section
would require that funding provided under this program is not recurring and would exclude such
grant funding from calculations of a tribe’s tribal shares under ISDEAA. The section would also
require that the facility would revert to the United States if it ceases to be used to provide
ambulatory care services to Indians.
30 40 U.S.C. 3141-3144, 3146, 3147.
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Section 306. Indian Health Care Delivery Demonstration Project
This section would authorize the Secretary to make grants to, or construction contracts or
agreements with, IT and TOs under ISDEAA to establish demonstration projects to test
alternative health care delivery systems through health facilities to Indians, including through
construction and renovation of hospitals, health centers, health stations, and other facilities. The
section would specify the uses of funds and permits their use to match federal and other funds.
The section would require the Secretary to promulgate regulations for application approval. It
also would establish granting criteria, the grant selection process, and the requirements for
technical assistance. In addition, under the demonstration projects, facilities would be allowed to
provide services to otherwise ineligible persons—that is those who are not eligible for IHS
services—and would extend hospital privileges in IHS facilities to non-IHS health practitioners.
The section would require that equal criteria be used in evaluating tribal and IHS facilities, and
would require integration of ISDEAA facility planning and construction into demonstration
projects.
Section 308. Leases, Contracts and Other Agreements
This section would authorize the Secretary to enter into leases, contracts, or other agreements
with ITs or TOs for the use of facilities owned or leased by ITs or TOs and used for the delivery
of health services by an IHP. The section would authorize the leases to include provisions for
construction or renovation and for compensation to ITs or TOs.
Section 309. Study on Loans, Loan Guarantees, and Loan Repayment
This section would require that the Secretary, in consultation with the Secretary of the Treasury
and ITs and TOs, carry out a study to determine the feasibility of a loan or loan guarantee fund to
provide ITs and TOs either direct loans or loan guarantees for the construction of health care
facilities. The section would require the Secretary to make 10 specified determinations, such as
the maximum principal amount and term of loans, amounts attributable for planning, appropriate
security for loans, and legislative or regulatory changes needed. The section also would require
the Secretary to submit a report to specified committees of Congress describing the consultations,
the study results, and any recommendations.
Section 311. Indian Health Service/Tribal Facilities Joint Venture Program
This section would require the Secretary to establish joint venture demonstration projects with
tribes and tribal organizations under which an IT or a TO would be required to expend funds,
from tribal or non-tribal sources, to acquire or construct a health facility (including staff quarters)
for at least 10 years, under a no-cost lease, in exchange for IHS agreement to provide staffing,
equipment, and supplies for the operation and maintenance of the facility. The section would
specify that tribes are eligible that have not begun, or have begun but not completed, the process
of acquiring or constructing a facility. The provision would require the Secretary to determine,
before entering into an agreement, whether the tribe or tribal organization meets criteria of need
under either the criteria developed under IHCIA Section 301 or other criteria as determined under
regulations. In addition, the section would require the Secretary to negotiate an agreement for the
continued operation of the facility at the end of the 10-year lease. The section would also
authorize recovery by tribes and organizations in a proportional amount from the United States
for non-use or other breaches of the lease agreement within the 10-year agreement period. In
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addition, the section would require that a IT or TO that breaches or terminates without cause such
an agreement liable for United States amounts paid, and grant the Secretary specified rights of
recovery.
Section 312. Location of Facilities
This section would require IHS and the BIA to give priority to locating facilities and projects on
Indian lands, and on any lands in Alaska owned by an Alaska Native village, a village or regional
corporation under the Alaska Native Claims Settlement Act,31 or allotted to an Alaska Native,
when developing or reorganizing IHS facilities or establishing related employment projects to
address unemployment conditions in economically depressed areas, if requested by the Indian
landowner and the IT with jurisdiction over the Indian lands. The section would require priority
be given to tribally-owned lands and defines “Indian lands” as all lands within the limits of any
Indian reservation and all trust or restricted lands over which a tribe exercises governmental
power.
Section 313. Maintenance and Improvement of Health Care Facilities
This section would require the Secretary to submit to the President, for inclusion in an annual
report to Congress, a report on the backlog of needed maintenance and repairs at IHS and tribal
health care facilities, and on the renovation and expansion needs of existing facilities to support
the growth of health care programs. The provision would limit the expenditure of IHS
maintenance and improvement funds for newly constructed space to an IT’s or TO’s approved
supportable space allocation (as defined through the health care facility priority system under
IHCIA Section 301). The provision would authorize ITs, and TOs to use maintenance and
improvement funds for renovation, modernization, and expansion, and for construction of
replacement facilities if the costs of renovation would exceed a maximum renovation cost
threshold, to be determined by the Secretary in consultation with ITs and TOs.
Section 314. Tribal Management of Federally Owned Quarters
This section would authorize THPs operating a health care facility and the associated federally-
owned quarters pursuant to an ISDEAA contract or compact to establish reasonable rental rates
for the federally-owned quarters, by notifying the Secretary, and to collect the rent directly. The
section would set the objectives of the THP’s rental rates, would require that such quarters remain
eligible for improvement and repair funds to the same extent as federally-owned quarters, and
would require at least 60 days’ notice before changes in the rental rate. In addition, the section
would specify requirements for direct rent collection by a THP, require federal employees subject
to the rent to pay the THP directly, and set the effective date for a retrocession of rent collection
authority. The provision would also allow rental rates in Alaska to be comparable to those in the
nearest established community with a year-round population of 1,500.
31 P.L. 92-203, act of Dec. 18, 1971, 85 Stat. 688, as amended; 43 U.S.C. 1601 et seq.
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Section 315. Applicability of Buy American Act Requirement
This section would require application of the Buy American Act for all procurements made with
funds appropriated under IHCIA Section 317 (authorizing appropriations for IHCIA Title III), but
exempts ITs and TOs from the requirements of the Buy American Act. The section would also set
a penalty for persons fraudulently affixing a “Made in America” label.
Section 316. Other Funding for Facilities
This section would authorize the Secretary to accept from any source, including federal and state
agencies, funds available for the construction of health care facilities, to use such funds for the
planning, design, and construction of Indian health facilities, and to place such funds in ISDEAA
contracts and compacts. In addition, the section would authorize the Secretary to enter into
interagency agreements with federal and state agencies or other entities, and to accept funds from
such agencies, for the planning, design, and construction of health care facilities to be
administered by an IHP. The section also would authorize any federal agency to which
appropriations are made for health care facilities construction to transfer the funds to the
Secretary for the construction of health care facilities to carry out the purposes of this act (i.e. to
improve Indian health) and the purposes for which the funds were originally appropriated. The
section would also require the Secretary to establish standards by regulation for the planning,
design, and construction of health care facilities for Indians.
Access To Federal Health Services and Reimbursements
IHCIA Title IV in Section 3101(a) authorizes IHS health-care facilities to receive reimbursements
from SSA’s Medicare and Medicaid programs. This authorization was a major component of the
original IHCIA passed in 1976. The title establishes a “special fund” to receive the
reimbursements and would specify what they can be used for. It also authorizes THPs to elect to
receive reimbursements directly, instead of through IHS. It excludes Medicare or Medicaid
reimbursements from being considered when determining annual Indian health appropriations and
would specify that IHS and THPs are the payer of last resort.
Sections 409, 410, 411, and 412 of IHCIA Title IV contain cross references to enacted SSA
amendments that affect Indian health care. Specifically, the Children’s Health Insurance Programs
Reauthorization Act (P.L. 111-3)32 and American Recovery and Reinvestment Act (ARRA, P.L.
111-5)33 amended Medicaid and CHIP statutes as they apply to American Indians and Alaska
Natives to require states to increase outreach, facilitate enrollment, and eliminate cost sharing for
eligible American Indians and Alaska Natives in Medicaid and CHIP. These cross references are
not included below.
In addition to amendments related to SSA programs, this title also includes sections related to
private insurance and sections related to coordination between IHS, the Department of Veterans
Affairs (VA), and the Department of Defense (DOD).
32 CRS Report R40130, The Children’s Health Insurance Program Reauthorization Act of 2009, by Evelyne P.
Baumrucker et al.
33 CRS Report R40223, American Recovery and Reinvestment Act of 2009 (ARRA, P.L. 111-5): Title V, Medicaid
Provisions, coordinated by Cliff Binder.
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Section 401. Treatment of Payments under SSA Health Benefits Programs
This section would require that payments received by an IHP or an UIO from Medicare,
Medicaid, or CHIP may not be considered in determining appropriations for Indian health care
services. The section also would prohibit the Secretary from providing services to Indians with
coverage under Medicare, Medicaid, or CHIP in preference to those Indians without such
coverage. The section also would require that Medicare and Medicaid payments to IHS facilities
be placed in a special fund to be held by the Secretary, and would require the Secretary to ensure
that each IHS service unit receives 100% of the reimbursed amounts to which the service unit’s
facilities are entitled. The section would require that amounts in the special fund be used by a
facility first (to the extent provided in appropriations acts) to improve IHS facilities so they can
comply with the applicable conditions and requirements of Medicare or Medicaid; if the
reimbursed amounts are in excess of the amount necessary to make such improvements, the
facility would be required to use the funds, after consulting with the tribes being served by the
service unit, to increase the facility’s capacity to provide services or to increase the quality or
accessibility of its services. The section would exclude THP electing to receive payments directly
from Medicare or Medicaid from making payments into, or receiving from, the special fund.
The section would authorize THP to elect to directly bill and receive payments from Medicare,
Medicaid, or CHIP. The section would require that payments be used for the same purposes as the
special fund, and subject the payments to all auditing requirements applicable both to whichever
programs it chooses to bill directly and to the IHP. The section would also require that a THP
receiving reimbursements or payments under Medicare, Medicaid, or CHIP provide to IHS a list
of each provider enrollment number (or other identifier) under which the THP receives such
reimbursements or payments and requires that IHS share this and other necessary information
with the Centers for Medicare and Medicaid Services (CMS), the agency that administers the
Medicare, Medicaid, and CHIP programs. The section would direct the Secretary, with assistance
from CMS, to examine and implement any administrative changes that would facilitate direct
billing and reimbursement, including agreements with states necessary to provide for direct
billing under Medicaid or CHIP. The section would allow participants (i.e. THPs) to withdraw
from the program under the same conditions that a tribe or tribal organization may retrocede a
contracted program under ISDEAA. In addition, the section would authorize the Secretary to
terminate a direct billing participant if the Secretary determines the participant has failed to
comply with certain specified requirements, but would require the Secretary to provide notice and
an opportunity to correct the non-compliance. The section cross-references specified sections of
the SSA relating to the special fund and the direct billing program (see Section 3201 below).
Section 402. SSA Health Benefit Programs Outreach and Enrollment Grants
This section would require the Secretary to make grants or enter into contracts with ITs and TOs
for programs on or near reservations, trust lands, and Alaska Native villages, including using
electronics and telecommunications, to assist individual Indians to enroll in Medicare, Medicaid,
and CHIP, and pay premiums and cost sharing required by the programs.34 Payment of premiums
and cost sharing may be based on need as determined by the IT or TO. The section would also
require the Secretary to place conditions as deemed necessary on the contracts and grants,
including requirements to determine Indian Medicaid, Medicare, and CHIP populations, educate
34 Section 508 of ARRA exempted American Indians and Alaska Natives from premiums and cost-sharing in Medicaid
and CHIP.
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Indians about the programs’ benefits, provide transportation, and develop and implement methods
to improve Indian participation in the programs. The section would also apply the enrollment,
premium, and cost-sharing assistance program to UIOs for the populations they serve, and set
requirements for agreements with such organizations. The section would also require the
Secretary, acting through CMS, to consult with states, IHS, ITs, TOs, and UIOs on developing
and disseminating best practices to facilitate agreements between the states, ITs, TOs, and UIOs
regarding enrollment and retention of Indians in Medicare, Medicaid, and CHIP. The section
cross-references SSA Section 1139 regarding agreements for collecting, preparing, and
submitting applications for Medicaid and CHIP. The section also defines the terms “premium,”
“cost sharing,” and “benefits.”
Section 403. Third Parties Reimbursements
This section would permit the United States, ITs, and TOs the right to recover reasonable charges
incurred (or, if higher, the highest amount a third party would pay for care and services from a
non-governmental provider), for health services provided by these entities to an individual, to the
same extent that the individual or any nongovernmental provider of health services would be
eligible to receive reimbursement or indemnification. The section would specify that entities from
whom recovery can occur include insurance companies, health maintenance organizations,
employee benefit plans, third-party tortfeasors, state political subdivisions, local governments, or
any other responsible or liable third parties. The section would limit the right of recovery against
any state to circumstances where the health services are covered under workers’ compensation
laws or a no-fault automobile accident insurance plan. The section would prohibit state or local
laws, contract provisions, insurance or health maintenance organization policies, employee
benefit plans, self-insurance plans, managed care plans, or other health care plans or programs
entered into or renewed after November 23, 1988, from preventing or hindering the right of
recovery. The section also would prohibit any action by the U.S, an IT, or TO from affecting the
right of an injured person to collect for the portion of their damages not covered hereunder. The
section would permit the United States, an IT, or a TO to enforce the right of recovery by
intervening or joining in specified civil actions or proceedings, or by instituting a separate civil
action (after notifying the individual or his representatives or heirs), and require reasonable
efforts to notify the individual. The section also would authorize ITs or TOs, independent of the
rights of the injured or diseased person, to recover from tortfeasors or their insurers the
reasonable value of health services provided or paid in accordance with the Federal Medical Care
Recovery Act.
The section would prohibit U.S. recovery from an IT’s or TO’s, or UIO’s self-insurance plan, but
allows recovery from a tribe if the tribal governing body provides specific written authorization
for a specified time period and allow expenditure of amounts recovered to provide additional
health services. The section would require award of reasonable attorneys fees and costs of
litigation to prevailing plaintiffs under this section, would prohibit specified health insurance and
related entities from denying reimbursement of an IHS or IT’s or TO’s claim on the basis of the
claim’s format (if the format meets certain standards), and applies a specified statute of
limitations.35 The section would apply to UIOs the same rights of recovery, for the populations
they serve, as the rights allowed to ITs and TOs for their populations served. The section would
35 28 U.S.C. 2415
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provide that nothing in this section limits the right of the United States, an IT, or a TO to recover
under any applicable federal, state, or tribal law, including medical lien laws.
Section 404. Crediting of Reimbursements
This section would require that—except as provided under IHCIA Section 20236 regarding the
CHEF or under IHCIA Section 806 regarding services to ineligible persons—all reimbursements
received or recovered for provision of health service by IHS, an IT, a TO, or a UIO, would be
required to be credited to the respective entity (including the service unit providing the health
service). The section would require that reimbursements be used as specified under IHCIA
Section 401. The section would also prohibit IHS from offsetting or limiting the amounts
obligated to any service unit, or any entity receiving IHS funding, because of the receipt of
reimbursements under this section.
Section 405. Purchasing Health Care Coverage
This section would authorize ITs, TOs, or UIOs to use funds made available for health benefits
for IHS beneficiaries under SSA programs and the ISDEAA (except for funds under IHCIA
Section 402) to purchase health benefits coverage that qualifies as creditable coverage under
PHSA Section 2701 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. The section would exclude specified types of coverage from eligibility,
namely, health flexible spending plans under IRC Section 106 and high deductible health plans as
defined in IRC Section 223. The section would permit that the coverage purchased may be based
on the financial needs of the individual beneficiaries (as determined by the tribes being served)
and would allow the use of funds for the expenses of operating a self-insured plan.
Section 406. Sharing Arrangements with Federal Agencies
This section would authorize the Secretary to enter or expand arrangements for IHS, tribes, and
tribal organizations to share medical facilities and services with the VA and the DOD, but require
consultation with affected tribes prior to finalizing an arrangement. The section would prohibit
the Secretary from taking any action under this section that would impair (1) an Indian’s priority
access to, or eligibility for, health care services provided through IHS, (2) a veteran’s priority
access to VA health care services, (3) the quality of IHS health care provided to an Indian, (4) the
quality of VA or DOD health care, or (5) an Indian veteran’s eligibility to receive VA health care.
The section would require reimbursement to the IHS, ITs, or TOs by the VA or DOD where
beneficiaries eligible for VA or DOD services receive care from the IHS, ITs, or TOs. The section
would prohibit construing the section as creating any right of a non-Indian veteran to IHS health
services.
Section 407. Eligible Indian Veteran Services
This section would make a Congressional findings that collaborations between the Secretary and
the VA for treatment of Indian veterans at IHS facilities, and increased enrollment for VA services
36 The bill specifies Section 202; however, it is likely referring to Section 226.
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by Indian tribal veterans, should both be encouraged to the maximum extent practicable, and
reaffirms the goals of a 2003 memorandum of understanding between IHS and VA’s Veterans
Health Administration regarding VA-authorized treatment of eligible Indian veterans at IHS
facilities. The section would require the HHS Secretary to provide for payment for veteran-
related, VA-authorized treatment under a local memorandum of understanding. The section would
require the HHS Secretary to establish guidelines for such payments to the VA, and prohibits use
of funds appropriated for IHS facilities, CHS, or contract support costs to make such payments.
The section would require the HHS Secretary to consult with affected tribes in negotiating local
memoranda of understanding, and define “eligible Indian veteran” and “local memorandum of
understanding.”
Section 408. Payor of Last Resort
This section would specify that IHPs and health care programs operated by UIOs would be the
payor of last resort for services provided to eligible persons.
Section 413. Navajo Nation Medicaid Agency Feasibility Study
This section would require the Secretary to conduct a study to determine the feasibility of treating
the Navajo Nation37 as a state for Medicaid purposes, for Indians living within the Navajo
Nation’s boundaries. The provision would require the Secretary to consider the feasibility of
certain options and to report the results of the study to specified committees of Congress not later
than three years after enactment of this act.
Health Services for Urban Indians
IHCIA Title V of Section 3101(a) directs the HHS Secretary to make contracts with or grants to
UIOs for health projects to serve urban Indians. The purpose of this program is to make IHS more
accessible and available to urban Indians. Such grants or contracts are under the authority of the
Snyder Act, not the ISDEAA.
There are 34 UIHPs. UIHPs may serve a wider range of eligible persons than the general IHS
health care programs, such as members of terminated or state-recognized tribes and their children
and grandchildren. These 34 UIHPs operate at 41 locations, with different programs offering
different services, such as ambulatory health care, health promotion and education,
immunizations, case management, child abuse prevention and treatment, and behavioral health
services.38 Besides IHS grants and contracts, UIHPs receive funding from state and private
sources, patient fees,39 Medicaid, Medicare, and other non-IHS federal programs.40
37 The Navajo reservation is located in parts of Arizona, Utah, and New Mexico.
38 U.S. Department of Health and Human Services, Public Health Service, Indian Health Service, Indian Health
Service: Fiscal Year 2010 Justification of Estimates for Appropriations Committees (Rockville, MD: HHS/PHS/IHS,
2009), p. CJ-133; http://www.ihs.gov/NonMedicalPrograms/BudgetFormulation/documents/documents/
IHS_CJ_2010_Final_Submission.pdf
39 IHS is forbidden to bill or charge Indians (see 25 U.S.C. 1681 and 25 USC 458aaa-14), but IHCIA Title V does not
prohibit UIHPs from charging their patients.
40 IHS, Office of Urban Indian Health Programs, Urban Indian Health Program Statistics, FY2005 ([Rockville, MD]:
IHS, October 16, 2007), p. 4.
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IHCIA Title V sets the requirements for the contracts and grants, and would expand the program
by authorizing residential treatment centers for urban Indian youth, grants for diabetes prevention
and treatment, and use of the Community Health Representatives program (see IHCIA Title I).
Section 502. Contracts With, and Grants To, Urban Indian Organizations
This section would require the Secretary, under authority of the Snyder Act, to enter contracts
with or make grants to UIOs to establish in urban centers programs that meet this IHCIA’s
requirements. The section would require the Secretary, subject to IHCIA Section 506, to include
in the contracts and grants such conditions as necessary.
Section 503. Contracts and Grants for Health Care and Referral Services
This section would include the requirements that the Secretary is subject to when making grants
or contracts to UIOs for health care services. The section would specify that contracts require
UIOs to estimate the population, health care needs and status of the urban Indians, provide basic
health education, make recommendations to federal, state, local, and other agencies for improving
health programs, and where necessary provide health care services for urban Indians directly or
through contracts. The section would also require the Secretary to prescribe selection criteria by
regulation and require inclusion of seven specified criteria, including the urban Indians’ unmet
health needs, extent of duplication of services already provided by health projects funded other
than by this title, and the UIO’s capability to perform the contract requirements. The section
would also require the Secretary, through the contracts and grants, to facilitate access to services
for health promotion and disease prevention, immunization, behavioral health, and child abuse
treatment and prevention. The section would also authorize the Secretary to contract with an UIO
to provide health services in more than one urban center.
Section 504. Use of Federal Government Facilities and Sources of Supply
This section would authorize the Secretary to (1) permit UIOs carrying out contracts or grants
under this title to use existing HHS facilities and equipment, (2) donate excess IHS or General
Services Administration real or personal property to such organizations, or (3) acquire excess or
surplus federal government real or personal property for donation to such organizations (subject
to a priority for tribes and tribal organizations). The section would permit UIOs carrying out
contracts or grants under this title to be deemed to be federal executive agencies under Section
201 of the Federal Property and Administrative Services Act of 1949, with access to federal prime
vendors, when the organizations are carrying out IHCIA Title V contracts or grants.
Section 505. Contracts and Grants to Determine Unmet Health Care Needs
This section would authorize the Secretary, under authority of the Snyder Act, to enter into
contracts with or make grants to UIOs in urban centers without contracts or grants under IHCIA
Section 503. Under these contracts/grants, the UIOs would determine health status and unmet
health care needs of the Indians in such urban centers and related information to help the
Secretary determine whether to enter into a contract with or make a grant, under Section 503, to
the UIO to provide services. The section would also prohibit the renewal of grants or contract
made under this section.
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Section 506. Evaluations and Renewals
This section would require the Secretary to develop procedures to evaluate UIO compliance with
and performance of contracts and grants. These procedures would be required to include either
annual onsite evaluations or evidence of the UIO’s accreditation by a recognized Medicare review
entity. The section would authorize non-renewal of contracts and grants and would require the
Secretary, if an evaluation reveals noncompliance with or non-performance of a grant or contract,
to attempt to resolve the area of noncompliance or nonperformance before renewing the contract
or grant. The section would also require the Secretary, before renewing the IHCIA Section 503
contract or grant of an organization that has completed a IHCIA Section 504 contract or grant, to
review an organization’s records, the onsite evaluations or accreditations, and reports under
IHCIA Section 507.
Section 507. Other Contract and Grant Requirements
This section would require that contracts with UIOs be in accordance with federal contracting
laws and regulations relating to procurement, except that the section allows, at the Secretary’s
discretion, contract negotiation without advertising as well as exemptions from specified federal
laws on contracts for federal buildings and works and on the sale of unneeded federal facilities to
states. The provision would authorize lump-sum advance payments (with a deadline) unless the
Secretary determines the UIO is not capable of administering such a payment; would authorize
semi-annual or quarterly payments or reimbursements to organizations without such capability;
and would require carrying forward unexpended payments. The section also would authorize
revision of contracts, if requested, and would require fair and uniform provision of services to
urban Indians.
Section 508. Reports and Records
This section would require urban Indian contractors and grantees under this title to submit semi-
annual reports to the Secretary containing specified information, including a minimum set of data
using uniform elements (specified by the Secretary after consultation with UIOs). The section
would make the contractors’ and grantees’ records subject to audit by the Secretary or GAO, and
would allow the cost of an annual outside audit by a certified public accountant or firm as a cost
of a contract or grant. The section would also require the Secretary, in consultation with UIOs, to
submit a report to Congress by 18 months after enactment on urban Indians’ health status,
services provided under this title, and unmet health needs, and would permit the Secretary to
contract with a national organization representing UIOs to conduct any aspect of the report.
Section 510. Facilities
This section would authorize the Secretary to make funds available to contractors or grantees for
leasing, purchasing, renovating, constructing, and expanding facilities, including leased facilities,
to comply with applicable licensure or certification requirements. The section would authorize the
Secretary to conduct a study of the feasibility of a loan fund for direct loans or loan guarantees to
UIOs for construction of health care facilities.
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Section 511. Division of Urban Indian Health
This section would establish a Division of Urban Health Programs within IHS responsible for
carrying out IHCIA Title V and overseeing the programs and services authorized.
Section 512. Grants for Alcohol and Substance Abuse-Related Services
This section would authorize the Secretary to make grants to urban Indian contractors and
grantees for the provision of alcohol and substance abuse services in urban centers, and would
require the Secretary to establish criteria for alcohol and substance abuse grants and to develop a
grant allocation methodology based on the criteria.
Section 515. Conferring with Urban Indian Organizations
This section would require the Secretary to ensure that IHS confers or conferences with UIOs to
the greatest extent practicable. It would define “confer” and “conference.”
Section 516. Urban Youth Treatment Center Demonstration
This section would require the Secretary to fund construction and operation of at least one
residential youth treatment center in each IHS Area meeting certain requirements to demonstrate
provision of alcohol and substance abuse treatment services for urban Indian youth in a culturally
competent residential setting. The section would require that such residential treatment centers be
in addition to facilities constructed under IHCIA Section 707. This section would also require
that, for a facility to be constructed, the IHS Area must include a UIO, have urban Indian youth
who need alcohol and substance abuse treatment in a residential setting, and have a significant
shortage of culturally competent residential treatment services.
Section 517. Grants for Diabetes Prevention, Treatment and Control
This section would authorize the Secretary to make grants to urban Indian contractors or grantees
for diabetes prevention, treatment, and control. The section would specify goals for each grant
and would require the Secretary to establish criteria for the grants, including the size and location
of the urban Indian population served, the population’s need for diabetes prevention, treatment,
and control, the organization’s performance standards and capability, and its willingness to
collaborate with the diabetes patient registry, if any, established by the Secretary in the IHS Area
under IHCIA Section 203(e).
Section 518. Community Health Representatives
This section would authorize the Secretary to contract with or make grants to urban Indian
organizations for the employment of Indians trained as health service providers through the
Community Health Representatives Program under IHCIA Section 109.
Section 521. Authorization of Appropriations
Besides authorizing appropriations, this section would authorizes the Secretary to establish
programs, including grants, for UIOs that are identical to programs established pursuant to IHCIA
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Section 126 (behavioral health training), Section 209 (school health education), Section 211
(prevention of communicable diseases), Section 701 (behavioral health prevention and treatment
services), and Section 707(g) (youth multidrug abuse program).
Section 522. Health Information Technology
This section would authorize the Secretary to make grants to UIOs under this title for the
development, adoption, and implementation of health information technology (HIT) (as defined
in Section 3000(5) of ARRA),41 telemedicine services development, and related infrastructure.
Organizational Improvements
IHCIA Title VI of Section 3101(a) would establish IHS’s organizational position. Under current
law, IHS is part of the PHS within HHS, and is administered by a director as established by
IHCIA Section 601. The sections below replace the IHS director with the new position of
Assistant Secretary of Indian Health. IHCIA Title VI would also authorize contracts and
agreements for enhancing information technology and systems.
Section 601. Establishment of IHS as a PHS Agency
This section would establish IHS within the PHS and establishes the position of Assistant
Secretary for Indian Health, to be appointed by the President and confirmed by the Senate, with a
term of four years. The section would specify the Assistant Secretary’s duties and responsibilities,
including managing funds, entering contracts, carrying out all functions relating to the
management of hospitals and facilities and all IHPs under specified acts, reporting to the
Secretary on Indian health policy and budget matters, interacting with other assistant secretaries
and agency heads on Indian health, and coordinating department activities on Indian health. The
section also would apply Indian preference under Section 12 of the Indian Reorganization Act42 to
IHS personnel actions for new positions resulting from its establishment under this section. The
section would deem any reference to the IHS director in federal laws, regulations, executive
orders, rules, or delegations of authority, or in documents relating to the director, to be a reference
to the Assistant Secretary.
Section 602. Automated Management Information System
This section would require the Secretary to establish automated management information systems
for IHS and for each THP, and sets requirements for the systems, including privacy regulations
under HIPAA. The section would require that patients, pursuant to HIPAA, have access to their
own health records held by or for IHS. The section would authorize the Secretary to enter into
contracts, agreements, or joint ventures with other federal agencies, states, and private and
nonprofit organizations to enhance information technology in IHPs.
41 P.L. 111-5, act of Feb. 17, 2009, 123 Stat. 115, 228; 42 USC 300jj.
42 P.L. 73-383, act of June 18, 1934, §12, 48 Stat. 984, 986; 25 U.S.C. 472.
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Behavioral Health Programs
IHCIA Title VII of Section 3101(a) covers behavioral health care programs. Under current law,
Title VII authorizes only alcohol and substance abuse programs; this bill would expand the
program to cover all mental and behavioral health programs, to create a “comprehensive
behavioral health prevention and treatment program” providing a “continuum of behavioral
health care” (see IHCIA Sections 701 and 703 of Section 3101(a)). IHCIA Title VII would define
a number of terms related to behavioral health care.
Section 701. Behavioral Health Prevention and Treatment Services
This section would include the purpose of the title, which includes directing the Secretary, acting
through IHS, to develop a comprehensive behavioral health care program that emphasizes
collaboration among alcohol and substance abuse, social services, and mental health programs.
The section would require the Secretary to encourage ITs, TOs, and UIOs to develop tribal, local,
and area-wide plans for Indian behavioral health services, to include assessments of specified
behavioral problems, the number of Indians affected, the financial and human costs, the existing
and necessary resources to prevent and treat such problems, and an estimate of necessary funding.
The section would require the Secretary to coordinate with existing national clearinghouses to
include such plans and any reports on their outcomes, ensure access to the plans and outcomes by
IHS, tribes, and tribal and urban Indian organizations, and provide technical assistance in the
development of these plans and related standards of care. The section also would require the
Secretary to provide, through IHS, and to the extent feasible and funded, a comprehensive
continuum of behavioral health care that includes nine specified services, including acute
hospitalization, detoxification, and emergency shelter, as well as specified services for Indian
children, adults, families, and elders. The section would authorize ITs, TOs and UIOs to establish
community behavioral health plans, would require IHS and BIA cooperation and assistance in
developing and implementing such plans, and would authorize grants to ITs and TOs for technical
assistance and administrative support for such plans. The section would require the Secretary,
through IHS, ITs, TOs, and UIOs, to coordinate behavioral health planning with other federal and
state agencies. The section would also require the Secretary, within one year of enactment, to
assess the need, availability, and cost for inpatient mental health care and facilities for Indians,
including possible conversion of existing, underused IHS hospital beds into psychiatric units.
Section 702. Memoranda of Agreement with the Department of the Interior
This section would require the Secretary and the Secretary of the Interior, not later than 12
months after enactment, to develop and enter into memoranda of agreement, or update
memoranda of agreement required by Section 4205 of the Indian Alcohol and Substance Abuse
Prevention and Treatment Act,43 covering eight specified activities, including a comprehensive
assessment and coordination of mental health care needs and services available or unavailable to
Indians, the ensuring and protection of Indians’ right of access to general mental health services,
and annual reviews of the agreement to be provided to Congress and tribes and tribal
organizations. The section would require that the memoranda include provisions assigning to IHS
responsibility for determining the scope of alcohol and substance abuse problems among Indians,
assessing existing and needed resources, and estimating necessary funding. The section also
43 P.L. 99-570, Title IV, subtitle C, act of Oct. 27, 1986, 100 Stat. 3207-137, as amended; 25 U.S.C. 2401 et seq.
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would require that each memorandum, renewal, or modification be published in the Federal
Register, with copies to ITs, TOs, and UIOs.
Section 703. Behavioral Health Prevention and Treatment Program
This section would require the Secretary to provide through IHS a program of comprehensive
behavioral health, prevention, treatment, and aftercare, including “Systems of Care,”(as defined
in IHCIA Section 716) for Indian tribal members, and requires that the comprehensive program
include prevention, education, specified treatments, rehabilitation, training, and diagnostic
services. The section would authorize the Secretary, through IHS, to provide the services through
contracts with public and private behavioral health providers, and would require the Secretary to
assist tribes and tribal organizations to develop criteria for certification of providers and
accreditation of facilities.
Section 704. Mental Health Technician Program
This section would require the Secretary, under the Snyder Act, to establish within IHS a mental
health technician training and employment program for Indians. The section also would require
the Secretary, through IHS, to provide high-standard paraprofessional training in mental health
care, to supervise and evaluate these technicians, and to ensure that the program includes using
and promoting traditional Indian health care practices of the tribes served.
Section 705. Licensing Requirement for Mental Health Care Workers
This section would require that, subject to IHCIA Section 221 (regarding licensing), any person
employed as a psychologist, social worker, or marriage and family therapist to provide mental
health care services to Indians in a clinic be licensed to provide the specified service. The section
would provide that a trainee in psychology, social work, or marriage and family therapy may
provide mental health care services if the trainee is directly supervised by someone licensed in the
specified service, is enrolled in or has completed at least two years of course work in an
accredited post-secondary education program for the specified service, and meet other
requirements that the Secretary may establish.
Section 706. Indian Women Treatment Programs
This section would authorize the Secretary, consistent with IHCIA Section 701, to make grants to
ITs, TOs, and UIOs to develop and implement a comprehensive behavioral health program for
prevention, intervention, treatment, and relapse prevention that specifically addresses the cultural,
historical, social, and childcare needs of Indian women. The section would specify uses of the
grants, including community training and education, counseling, support, and development of
prevention and intervention models. The section also would require the Secretary, in consultation
with ITs and TOs, to establish grant approval criteria, and to allocate 20% of the program’s funds
for grants to UIOs.
Section 707. Indian Youth Program
This section would establish a number of Indian youth behavioral health programs. The section
would require the Secretary, consistent with IHCIA Section 701, to develop and implement a
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program for acute detoxification and treatment for Indian youth, including behavioral health
services, regional treatment centers with detoxification and rehabilitation services, and local
programs developed by tribes or tribal organizations under ISDEAA. The section would require
the Secretary, through IHS, to construct, renovate, or purchase, and staff and operate (under the
Snyder Act) at least one youth regional treatment center or treatment network in each IHS area
(treating the California Area as two areas), in a location agreed upon by a majority of the area’s
tribes; the section also would authorize funding to two specified Alaska Native entities for youth
treatment facilities in Alaska. The section would authorize the Secretary to provide intermediate
behavioral health services for Indian children and adolescents, and would specify that such
services include pretreatment assistance, inpatient, outpatient, and aftercare services, emergency
care, suicide prevention, and prevention and treatment of mental illness and dysfunctional and
self-destructive behavior, including child abuse and family violence. The section would set the
allowable uses of funds for intermediate behavioral health services, and requires the Secretary, in
consultation with ITs and TOs, to develop grant approval criteria.
The section also would require the Secretary, in consultation with ITs and TOs, to identify and use
suitable federally-owned structures for local residential or regional behavioral health treatment
for Indian youths, and establish suitability guidelines. The section allows use of any such
federally-owned structure under terms agreed upon by the Secretary, the responsible federal
agency, and the IT or TO operating the program. The section also would require the Secretary,
ITs, and TOs, in cooperation with the Interior Secretary, to develop local community-based
rehabilitation and aftercare services in each IHS service unit for Indian youths with significant
behavioral health problems, including long-term treatment, community reintegration, and
monitoring, to be provided by trained staff. The section would require the Secretary, in providing
services under this section, to provide for inclusion of family in such services, and would specify
that not less than 10% of funds for the local rehabilitation and aftercare services program would
be permitted to be used for outpatient care of adult family members of an Indian youth in the
program. The section also would require the Secretary, through IHS, to provide programs and
services to prevent and treat multi-drug abuse among Indian youths in Indian communities, on or
near reservations, and in urban areas, and provide appropriate mental health services. The section
would require the Secretary to collect data on specified aspects of Indian youth mental health for
the report under IHCIA Section 801.
Section 708. Indian Youth Telemental Health Demonstration Project
This section would authorize the Secretary to carry out a demonstration project by making four-
year grants to not more than five tribes and tribal organizations with telehealth capabilities to use
for telemental health services in youth suicide prevention and treatment. The section would define
terms and would direct the Secretary to give priority to ITs and TOs that serve tribal communities
that have a demonstrated need or are isolated and have limited access to mental health services, or
that enter into collaborative partnerships to provide the services, or that operate a detention
facility where youth are detained. The section would describe the uses of the grants, including 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; data collection
and reporting; and the use of the tribe’s traditional health care practices. The section would
include requirements for grant applications, encourages collaboration among grantees and grantee
reports to the national clearinghouse under IHCIA Section 701, and would require grantees to
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submit annual reports to the Secretary. In addition, the section would require the Secretary to
submit a report to specified committees of Congress no later than 270 days after termination of
the demonstration project. The report would include evaluations of whether the project should be
made permanent or expanded to more than five grants and to UIOs. The section would authorize
appropriations of such sums as may be necessary to carry out this section.
Section 709. Mental Health Facilities Design, Construction, and Staffing
This section would authorize the Secretary, through IHS, to provide in each IHS area, not less
than one year after enactment, at least one inpatient mental health facility for Indians with
behavioral health problems. The section would require that California be considered two areas
and would require the Secretary to consider the conversion of existing underused IHS hospital
beds into psychiatric units to meet the need for such facilities.
Section 710. Training and Community Education
This section would require the Secretary, in cooperation with the Interior Secretary, develop and
implement in each IHS service unit or tribal program a program of community education and
involvement for specified tribal community leaders in behavioral health issues, possibly including
community-based training, or assist tribes and tribal organizations to do so. The section also
would require the Secretary to provide specified instruction in behavioral health issues to
appropriate IHS and BIA employees and personnel in contracted IHS and BIA programs and
schools.44 In addition, this section would require the Secretary, as part of the community
education and employee instruction programs, to develop and provide community-based training
models addressing specified aspects of behavioral health problems, in consultation with ITs, TOs,
and Indian alcohol and substance abuse prevention experts.
Section 711. Behavioral Health Program
This section would authorize the Secretary, through IHS, to develop and implement programs to
deliver innovative community-based behavioral health services to Indians, and authorizes grants
to tribes and tribal organizations for such programs. The section would specify criteria for
awarding such grants, and would require the Secretary to use the same criteria in evaluating all
project applications.
Section 712. Fetal Alcohol Disorder Programs
This section would authorize the Secretary, through IHS, to develop and implement fetal alcohol
disorder (FAD) programs (as defined in IHCIA Section 4), consistent with IHCIA Section 701,
and to establish criteria for approval of funding applications. The section would specify grant
uses, including developing and providing services for the prevention, intervention, treatment, and
aftercare for those affected by FAD, early childhood intervention projects, supportive services,
and housing. The section also would require the Secretary, through IHS, to provide FAD
prevention, treatment, and aftercare services as well as specified support services; would require
44 The BIA’s educational programs were transferred to a new agency, the Bureau of Indian Education (BIE), in 2006.
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the Secretary to establish a Fetal Alcohol Disorder Task Force for advice on providing these
services; and would specify the membership of the Task Force.
The section would require the Secretary to make grants through the Substance Abuse and Mental
Health Services Administration (SAMHSA) in HHS to ITs, TOs, and UIOs for applied research
projects to elevate the understanding of methods to prevent, intervene, treat, or provide
rehabilitation and aftercare for Indians affected by fetal alcohol spectrum disorders. The section
would require that 10% of appropriations under this section be used for grants to UIOs funded
under IHCIA Title V.
Section 713. Child Sexual Abuse and Prevention Treatment Programs45
This section would require the Secretary, through IHS, and consistent with IHCIA Section 701, to
establish in every IHS Area treatment programs for child victims of sexual abuse and perpetrators
of child sexual abuse who are Indians or members of Indian households. The provision would
specify five uses of funding, including developing community education, identifying and
providing treatment to victims, developing culturally-sensitive prevention models and diagnostic
tools, and providing treatment to perpetrators. The section would require that the programs be
carried out in coordination with programs and services authorized under the Indian Child
Protection and Family Violence Prevention Act.46
Section 714. Domestic and Sexual Violence Prevention and Treatment
This section would authorize the Secretary to establish programs in each IHS Area to prevent and
treat Indian victims and perpetrators of domestic violence or sexual violence. The section would
require program funds be used for prevention and community education programs, behavioral
health services and medical treatment for victims (including examinations by sexual assault nurse
examiners), rape kits, development of prevention and intervention models (including traditional
health care), and identification and treatment of Indian perpetrators. The section would require the
Secretary to establish protocols, policies, procedures, standards, training curricula, and training
and certification requirements for victim services within one year of enactment, and requires a
report on these activities to specified committees of Congress within 18 months of enactment.
The section also would require the Secretary, in coordination with the Attorney General, federal
and tribal law enforcement agencies, IHPs, and victim organizations, to develop victim services
and victim advocate training programs, for specified purposes; and requires the Secretary to
report to specified committees of Congress on such services and programs, including
improvements, obstacles, costs needed to address the obstacles, and any recommendations.
Section 715. Behavioral Health Research
This section would require the Secretary, in consultation with appropriate federal agencies, to
make contracts with or grants to ITs, TOs and UIOs, and appropriate institutions for research on
the incidence and prevalence of behavioral health problems among Indians served by IHS, ITs, or
TOs and in urban areas. The section would direct that research priorities include the multifactorial
causes of Indian youth suicide; the interrelationship of behavioral health problems with
45 Section 713’s title may be intended to read, “Child Sexual Abuse Prevention and Treatment Programs.”
46 P.L. 101-630, Title IV, act of Nov. 28, 1990, 104 Stat. 4544, as amended; 25 U.S.C. 3202 et seq., 18 U.S.C. 1169.
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alcoholism, suicide, homicide, and family violence, especially on children; and the development
of models of prevention techniques, especially as regards children.
Miscellaneous
IHCIA Title VIII of Section 3101(a) includes a number of separate provisions covering reports,
regulations, abortion, certain persons’ eligibility for IHS services, criminal jurisdiction of a
tribally operated hospital in Oklahoma, and a variety of other topics.
Section 801. Reports
This section would require the Secretary to submit to Congress each fiscal year a report
containing 23 specified reports, including 18 reports required under other IHCIA sections. Among
the proposed topics of specified reports are the progress made in meeting health objectives,
impacts of new national programs, Indian use of health services including CHS, funding
requested under IHCIA Section 201, infectious diseases, health care and sanitation facilities
status, maintenance and repair backlogs, program evaluations, effects of the movement of patients
between IHS service units, and the extent of compliance with IHS credentialing and state
licensing requirements.
Section 802. Regulations
This section would require the Secretary, within 90 days of enactment, to initiate negotiated
rulemaking for regulations to carry out IHCIA, except for specified sections for which
rulemaking under the Administrative Procedures Act47 is authorized. The section would establish
a deadline of two years after enactment for the Secretary to publish proposed regulations in the
Federal Register, with a minimum comment period of 120 days, and would establish a deadline of
three years after enactment to publish final regulations. The section would require that any
negotiated rule-making committee under this section consist only of representatives of ITs, TOs,
and the federal government, and would require the Secretary to adapt negotiated rulemaking to
the context of self-governance and the government-to-government relationship. The section
would prohibit lack of regulations from limiting the effect of IHCIA.
Section 803. Plan of Implementation
This section would require the Secretary, not less than one year after enactment, and in
consultation with ITs, TOs, and UIOs, to submit to Congress a plan detailing by title and section
how IHCIA would be implemented. The section would specify that lack of such a plan would not
limit the effect, or prevent the implementation, of IHCIA.
Section 804. Limitation on Use of Funds Appropriated to Indian Health Service
This section would provide that any limitation contained in HHS appropriations on the use of
federal funds for abortions would be required to apply for that period with respect to funds
appropriated for IHS.
47 5 U.S.C., Chap. 5, subchap. II, and Chap. 7.
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Section 805. Eligibility of California Indians
This section would make specified California Indians eligible for IHS health services, including
members of federally-recognized tribes, descendants of Indians residing in California as of June
1, 1852 (if they are members of a community served by a local IHS program and regarded as
Indian), Indians holding trust interests in certain types of land allotments in California, and
Indians (and their descendants) listed on the plans for asset distribution in California under the act
of August 18, 195848 (terminating federal recognition of certain California tribes). The section
would prohibit construing anything in the section as expanding California Indians’ eligibility for
IHS health services beyond their eligibility as of May 1, 1986.
Section 806. Health Services for Ineligible Persons
This section would authorize IHS health services for certain ineligible persons who are children
or (if the governing body of the tribe or tribal organization agrees) spouses of eligible Indians.
For otherwise ineligible persons (who are not children or spouses) who reside in an IHS service
unit’s service area, at IHS-operated programs, the section would authorize the Secretary to
provide health services, if requested by the tribes served and if the Secretary and the tribes
determine that provision of such services will not result in denial or diminution of health services
to eligible Indians and that there are no reasonable alternative health facilities or services in or
outside the service unit. For otherwise ineligible persons (not children or spouses) at health
facilities operated by ITs or TOs under ISDEAA contracts and compacts, the section would
authorize the governing body of such ITs or TOs to determine whether to provide services to such
ineligible persons. The section would require reimbursement from otherwise ineligible persons of
not less than the actual costs for IHS-provided health services; direct that reimbursements,
including under Medicare, Medicaid, or CHIP, be credited to the facility providing the service for
the purposes listed in IHCIA Section 401; and would authorize the Secretary to provide health
services through IHS for indigent persons not otherwise eligible, but only if the state or local
government agrees to reimburse IHS for the expenses it incurs. The section would provide that
tribes may revoke their consent to provision of health services to any otherwise ineligible persons
(not children or spouses). The section also would authorize IHS to provide health services to
otherwise ineligible persons to achieve stability in a medical emergency, prevent the spread of a
communicable disease, deal with a public health hazard, provide care to a non-Indian woman
pregnant with an eligible Indian’s child, or provide care to immediate family members if such
care is directly related to the treatment of an eligible individual. The section would authorize
extending hospital privileges to non-IHS health care practitioners who provide services to certain
ineligible persons, and also permit such practitioners to be designated as federal employees for
the purposes of the Federal Tort Claims Act,49 but only while providing services to eligible
individuals under the conditions under which such hospital privileges are extended.
Section 807. Reallocation of Base Services
This section would prohibit any allocation of IHS funding in a fiscal year that reduces an IHS
service unit’s recurring programs, projects, or activities by 5% or more from the previous fiscal
year unless the Secretary has submitted to Congress a report on the proposed change, the reasons
48 P.L. 85-671, act of Aug. 18, 1958, 72 Stat. 619, as amended.
49 P.L. 79-601, act of Aug. 2, 1946, Title IV, 60 Stat. 842, as amended; 28 U.S.C., Chap. 171.
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for the change, and the likely effects. The section exempts the section from applying if total IHS
appropriations for a fiscal year are at least 5% less than the previous fiscal year.
Section 809. Moratorium
This section would make permanent language that has been repeated in annual IHS
appropriations acts since FY1989.50 Specifically, this section would require IHS to provide
services according to eligibility criteria effective September 15, 1987, subject to IHCIA Sections
805 and 806, until enactment of specified appropriations to pay for increased costs of new
eligibility criteria issued under a final rule that was published in the Federal Register on
September 16, 1987.
Section 812. Use of Patient Safety Organizations
This section would authorize IHS, an IT, or a TO, or a UIO to use a patient safety organization to
provide for quality assurance activities, in accordance with PHSA Title IX.
Section 813. Medical Quality Assurance Records Confidentiality
This section would make medical quality assurance records created by an IHP or a UIHP
confidential and privileged, and prohibit their disclosure except to specified entities for specified
purposes. The section would exempt such records from the Freedom of Information Act,51 require
the Secretary to promulgate regulations, and define terms.
Section 817. Authorization of Appropriations; Availability
In addition to appropriations, this section would subject new spending authority (as described in
Section 401 of the Congressional Budget Act of 197452 provided under IHCIA to the availability
of appropriations. The section also makes funds appropriated under IHCIA available until
expended.
Other Sections of Title I of Division D
The provisions in subsections 3101(b)-(c) of Title I make technical corrections in other federal
laws, including Executive Schedule pay laws, necessitated by IHCIA Section 601’s creation of a
new Assistant Secretary for Indian Health. The other sections of Division D (Sections 3102 and
3103) authorize the establishment of a new foundation and require a GAO report.
50 P.L. 100-446, act of Sept. 27, 1988, 102 Stat. 1774, 1817. Section 315 of the continuing appropriations act for
FY1988 (P.L. 100-202, act of Dec. 22, 1987, 101 Stat. 1329, 1329-254 – 1329-255) had delayed implementation of the
final rule until Sept. 16, 1988.
51 5 U.S.C. 552
52 2 U.S.C. 651
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Section 3102. Native American Health and Wellness Foundation
This section would amend ISDEAA by adding a new title, Title VIII, Native American Health and
Wellness Foundation(Foundation). This new title would direct the Secretary to establish the
Foundation and a committee to assist in establishing the Foundation, and would specify that the
Foundation’s duties would be to encourage, accept, and administer private gifts of property and
income for the benefit of, or in support of, the mission of IHS; to undertake activities that will
further the health and wellness activities and opportunities of Native Americans; and to
participate with and assist federal, state, and tribal governments, agencies, entities, and
individuals in such undertaking. The new title would establish the Foundation’s powers, Board of
Governors, and officers, and make the existence of the Foundation perpetual. The new title would
also define terms, limits administrative costs, requires audits, authorizes appropriations of
$500,000 for each fiscal year (to be adjusted to reflect changes in the Consumer Price Index for
all-urban consumers), and direct the Secretary to transfer to the Foundation funds donated for
Indian health and held by HHS.
Section 3103. GAO Study and Report on Payments for Contract
Health Services
This section would require GAO, in consultation with IHS, ITs, and TOs, to study use of health
care services provided under the CHS program. The section would require the study to include
analyses of amounts reimbursed to providers, suppliers, and entities under CHS, with comparison
to reimbursements through other public programs and the private sector; barriers to access to
health care under CHS; adequacy of federal funding of CHS; and other items GAO determines
appropriate. The section would require GAO to report to Congress on the study within 18 months
after enactment, with recommendations on appropriate federal funding for CHS and ways to use
such funding efficiently.
Title II of Division D: Improvement of Indian
Health Care Provided under the SSA
Separate from the reauthorization of the IHCIA in Section 3101(a), Division D would amend
several sections of the SSA specifically those related to titles XVIII (Medicare), XIX (Medicaid),
XXI (CHIP), and XI (general provisions).
H.R. 3962 would amend the SSA to define a number of Indian terms as they are defined in IHCIA
Section 4. These terms include IHS, IT, TOs, and UIOs, IHPs and THPs. These definitions would
apply for all of the SSA including Medicare, Medicaid and CHIP. Section 3201 also includes
these definitions as related to amending SSA Sections 1101, 1911, 1880, and 2107.
Section 3201. Expansion of Payments under SSA Health Benefit Programs
(a) Medicaid
This subsection would amend SSA Section 1911(a) to provide that IHPs are eligible for Medicaid
payments for all items and services provided under a state plan or under a waiver, if the provision
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of those services meets all the conditions and requirements generally applicable to the delivery of
such care. The subsection would repeal SSA Section 1911(b) regarding IHS-funded facilities that
do not yet meet all conditions and requirements. The subsection would amend SSA Section
1911(c)53 to permit the Secretary to enter into an agreement with a state for the purpose of
reimbursing that state for Medicaid services provided by the IHS, an IT, TO, or UIO, either
directly, through referral, under contracts or other arrangements between these entities and
another health care provider, to Indians eligible for Medicaid under the state Medicaid plan or a
waiver. The subsection strikes SSA Section 1911(d). It would add a new SSA Section 1911(c)54
that cross-references the special fund for improvement of IHS facilities in IHCIA Section
401(c)(1) (as amended). It also would add a new Section 1911(d) that cross-references direct-
billing provisions in IHCIA Section 401(d) (as amended).
(b) Medicare
This subsection would amend and renumber sections of SSA Section 1880. It would amend SSA
1880(a), regarding Medicare payments to IHS hospitals, to specify that, subject to SSA Section
1880(e) (regarding Medicare physician payments to IHS, IT, and TO facilities) that IHPs are
eligible for Medicare payments for items and services furnished by IHPs, provided that the
services provided meet all the conditions and requirements generally applicable to delivery of
such care under the Medicare program. The subsection would repeal SSA Sections 1880(b)
regarding IHS-funded facilities that do not yet meet all conditions and requirements, 1880(c)
regarding the special fund for improvement of IHS facilities, and 1880(d) regarding a compliance
status report. It would add new Sections 1880(b) and 1880(c) to cross-reference the special fund
established under IHCIA Section 401(c) (as amended) and cross-reference the direct billing
authority in IHCIA Section 401(d) (as amended). The subsection would also make a conforming
change to existing SSA Section 1880(e)(3) (as amended), regarding Medicare Part B payments, to
specify that IHCIA Section 401(c)(1) (as amended) and new SSA Section 1880(b), both regarding
the special fund, would not apply to payments made under SSA Section 1880(e).
(c) Application to CHIP
This subsection would amend SSA Section 2107 (regarding Medicaid provisions applicable to
CHIP) to apply all but one of the Medicaid provisions in SSA Section 201(a) as amended, above,
to the CHIP program, including the provisions regarding eligibility of Indian entities to receive
Medicaid reimbursement, compliance with conditions and requirements, agreements with states
to provide Medicaid reimbursement to Indian, direct billing, and definitions of Indian terms. The
provision regarding the special fund for improvement of IHS facilities (as defined in the new SSA
Section 1911(c))55 would not apply to CHIP.
Section 3202. Outreach and Enrollment Indians in CHIP and Medicaid
This section would amend SSA Section 2102, regarding assurances required in state CHIP plans,
to strike the definition of “Indian” by reference to IHCIA Section 4(c) from the requirement for a
53 Reference to Section 1911(c) appears to be a drafting error and may refer to Section 1911(b).
54 Section 1911(c) would likely need to be renumbered based on the other amendments made to SSA Section 1911 in
this section.
55 See above discussion of renumbering.
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description in the plan of procedures to ensure the provision of child health assistance to targeted
low-income Indian children in the state, and add to the requirement a description of how the state
will ensure that payments are made to Indian health programs and urban Indian organizations
providing CHIP benefits in the state. The section also would amend SSA Section 2105 regarding
the prohibition of CHIP payments where other federal payments can be made, to exempt health
care programs operated or financed by IHS, tribes, and TOs and UIOs from such prohibitions
(currently only IHS programs are exempted).
Section 3203. SSA Safe Harbor Proposals for IHPs and UIOs
SSA Sections 1128 and 1128B and related provisions exclude certain activities for individuals
and entities under federal health programs, but allow waivers and “safe harbors” under certain
circumstances. Among the excluded activities are knowingly and willfully soliciting or receiving
remuneration in return for referrals for services for which a federal health program payment may
be made, or in return for purchasing, leasing, or ordering (or arranging for same) any good,
facility, service, or item for which a federal health program payment may be made. This section
would direct the Secretary, through the HHS Inspector General, to publish a notice soliciting a
proposal, on the development of safe harbors as described for health care items and services
provided by IHPs or UIOs. The section would suggest potential areas that these safe harbor may
relate to.
Section 3204. SSA Health Benefit Programs Annual Report on Indians Served
This section would amend SSA Section 1139, as amended, to add a new subsection 1139(e),
which would require the Secretary, acting through CMS and IHS, to submit an annual report to
Congress covering the enrollment and health status of Indians receiving items or services under
the health benefit programs funded under the SSA during the preceding year. The section would
specify the information to be included in the report, including the number of Indians enrolled in
or receiving items or services under each such SSA program and under programs funded by IHS;
the health status of these Indians, disaggregated by diseases or conditions consistent with
individual privacy; the status of IHS, ITs, TOs, or UIOs facilities’ compliance with the applicable
terms and conditions under Medicare, Medicaid, and CHIP, and the progress being made by such
facilities toward achievement and maintenance of compliance; and such other information as the
Secretary determines appropriate.
Section 3205. Interstate Coordination Study
This section would require the Secretary to conduct a study to identify barriers to interstate
coordination of enrollment and coverage of Medicaid- and CHIP-enrolled children who
frequently change their state of residence or may be temporarily outside their state of residence
for a variety of reasons (e.g., educational needs, family migration, or emergency evacuations).
The section would require that the study include an examination of enrollment and coverage
coordination issues faced by Medicaid- and CHIP-enrolled Indian children temporarily residing
in an out-of-state BIA boarding school or peripheral dormitory. 56 The section would also require
the Secretary, in consultation with state Medicaid and CHIP directors, to submit a report to
Congress, not later than 18 months after enactment, containing recommendations for legislative
56 The BIA’s educational programs were transferred to a new agency, the Bureau of Indian Education (BIE), in 2006.
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and administrative actions to address the enrollment and coverage coordination barriers identified
in the study.
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Appendix. Acronyms used in the Report
ARRA
American Recovery and Reinvestment Act
BIA
Bureau of Indian Affairs
BIE
Bureau of Indian Education
CDC
Centers for Disease Control and Prevention
CHAP
Community Health Aide Program
CHEF
Catastrophic Health Emergency Fund
CHIP
Children’s Health Insurance Program
CHR
Community Health Representative
CHS
Contract Health Services
CMS
Centers for Medicare and Medicaid Services
DOD
Department of Defense
FAD
fetal alcohol disorder
GAO
Government Accountability Office
HHS
Department of Health and Human Services
HIPAA
Health Insurance Portability and Accountability Act
HIT
Health Information Technology
HUD
Department of Housing and Urban Development
IHCIA
Indian Health Care Improvement Act
IHCIF
Indian Health Care Improvement Fund
IHP
Indian Health Program
IHS
Indian Health Service
INMED
Indians into Medicine Program
IRC
Internal Revenue Code
ISDEAA
Indian Self-Determination and Education Assistance Act
IT
Indian tribe
NHSC
National Health Service Corp
PHS
Public Health Service
PHSA
Public Health Service Act
SCHIP
State Children’s Health Insurance Program
SSA
Social Security Act
SAMSHA
Substance Abuse and Mental Health Services Administration
THP
Tribal Health Program
TO
tribal organization
UIHP
urban Indian health project
UIO
urban Indian organization
USPSTF
United States Preventive Services Task Force
VA
Department of Veterans Affairs
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Author Contact Information
Roger Walke
Elayne J. Heisler
Specialist in American Indian Policy
Analyst in Health Services
rwalke@crs.loc.gov, 7-8641
eheisler@crs.loc.gov, 7-4453
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