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109TH CONGRESS 2D SESSION
HOUSE OF REPRESENTATIVES
Rept. 109-661

Part 1

INDIAN HEALTH CARE IMPROVEMENT ACT

AMENDMENTS OF 2006

R E P O R T

of the

COMMITTEE ON RESOURCES

[to accompany h.r. 5312]

[Graphic image not available]

SEPTEMBER 15, 2006- Ordered to be printed

INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2006

49-006

109TH CONGRESS

REPT. 109-661

HOUSE OF REPRESENTATIVES

2d Session

Part 1

--INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2006

SEPTEMBER 15, 2006- Ordered to be printed

Mr. POMBO, from the Committee on Resources, submitted the following

R E P O R T

[To accompany H.R. 5312]

[Including cost estimate of the Congressional Budget Office]

The Committee on Resources, to whom was referred the bill (H.R. 5312) to amend the Indian Health Care Improvement Act to revise and extend that Act, having considered the same, report favorably thereon with an amendment and recommend that the bill as amended do pass.

The amendment is as follows:

Strike all after the enacting clause and insert the following:

SECTION 1. SHORT TITLE.

This Act may be cited as the `Indian Health Care Improvement Act Amendments of 2006'.

TITLE I--INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS

SEC. 101. INDIAN HEALTH CARE IMPROVEMENT ACT AMENDED.

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

`SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

`(a) SHORT TITLE- This Act may be cited as the `Indian Health Care Improvement Act'.

`(b) TABLE OF CONTENTS- The table of contents for this Act is as follows:

`Sec. 1. Short title; table of contents.

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

`Sec. 101. Purpose.

`Sec. 102. Health professions recruitment program for Indians.

`Sec. 103. Health professions preparatory scholarship program for Indians.

`Sec. 104. Indian health professions scholarships.

`Sec. 105. American Indians into psychology program.

`Sec. 106. Scholarship programs for Indian tribes.

`Sec. 107. Indian health service extern programs.

`Sec. 108. Continuing education allowances.

`Sec. 109. Community health representative program.

`Sec. 110. Indian health service loan repayment program.

`Sec. 111. Scholarship and loan repayment recovery fund.

`Sec. 112. Recruitment activities.

`Sec. 113. Indian recruitment and retention program.

`Sec. 114. Advanced training and research.

`Sec. 115. Quentin N. Burdick American Indians into nursing program.

`Sec. 116. Tribal cultural orientation.

`Sec. 117. Inmed program.

`Sec. 118. Health training programs of community colleges.

`Sec. 119. Retention bonus.

`Sec. 120. Nursing residency program.

`Sec. 121. Community health aide program for Alaska.

`Sec. 122. Tribal health program administration.

`Sec. 123. Health professional chronic shortage demonstration programs.

`Sec. 124. National Health Service Corps.

`Sec. 125. Substance abuse counselor educational curricula demonstration programs.

`Sec. 126. Behavioral health training and community education programs.

`TITLE II--HEALTH SERVICES

`Sec. 201. Indian Health Care Improvement Fund.

`Sec. 202. Catastrophic Health Emergency Fund.

`Sec. 203. Health promotion and disease prevention services.

`Sec. 204. Diabetes prevention, treatment, and control.

`Sec. 205. Shared services for long-term care.

`Sec. 206. Health services research.

`Sec. 207. Mammography and other cancer screening.

`Sec. 208. Patient travel costs.

`Sec. 209. Epidemiology centers.

`Sec. 210. Comprehensive school health education programs.

`Sec. 211. Indian youth program.

`Sec. 212. Prevention, control, and elimination of communicable and infectious diseases.

`Sec. 213. Authority for provision of other services.

`Sec. 214. Indian women's health care.

`Sec. 215. Environmental and nuclear health hazards.

`Sec. 216. Arizona as a contract health service delivery area.

`Sec. 216A. North Dakota as a contract health service delivery area.

`Sec. 216B. South Dakota as a contract health service delivery area.

`Sec. 217. California contract health services program.

`Sec. 218. California as a contract health service delivery area.

`Sec. 219. Contract health services for the Trenton service area.

`Sec. 220. Programs operated by Indian tribes and tribal organizations.

`Sec. 221. Licensing.

`Sec. 222. Notification of provision of emergency contract health services.

`Sec. 223. Prompt action on payment of claims.

`Sec. 224. Liability for payment.

`Sec. 225. Authorization of appropriations.

`TITLE III--FACILITIES

`Sec. 301. Consultation: construction and renovation of facilities; reports.

`Sec. 302. Sanitation facilities.

`Sec. 303. Preference to Indians and Indian firms.

`Sec. 304. Expenditure of nonservice funds for renovation.

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

`Sec. 306. Indian health care delivery demonstration project.

`Sec. 307. Land transfer.

`Sec. 308. Leases, contracts, and other agreements.

`Sec. 309. Study on loans, loan guarantees, and loan repayment.

`Sec. 310. Tribal leasing.

`Sec. 311. Indian health service/tribal facilities joint venture program.

`Sec. 312. Location of facilities.

`Sec. 313. Maintenance and improvement of health care facilities.

`Sec. 314. Tribal management of federally owned quarters.

`Sec. 315. Applicability of Buy American Act requirement.

`Sec. 316. Other funding for facilities.

`Sec. 317. Authorization of appropriations.

`TITLE IV--ACCESS TO HEALTH SERVICES

`Sec. 401. Treatment of payments under Social Security Act health benefits programs.

`Sec. 402. Grants to and contracts with the service, Indian tribes, tribal organizations, and urban indian organizations to facilitate outreach, enrollment, and coverage of indians under social security act health benefit programs and other health benefits programs.

`Sec. 403. Reimbursement from certain third parties of costs of health services.

`Sec. 404. Crediting of reimbursements.

`Sec. 405. Purchasing health care coverage.

`Sec. 406. Sharing arrangements with Federal agencies.

`Sec. 407. Payor of last resort.

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

`Sec. 409. Consultation.

`Sec. 410. State children's health insurance program (SCHIP).

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

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

`Sec. 413. Treatment under Medicaid and SCHIP managed care.

`Sec. 414. Navajo nation Medicaid agency feasibility study.

`Sec. 415. Authorization of appropriations.

`TITLE V--HEALTH SERVICES FOR URBAN INDIANS

`Sec. 501. Purpose.

`Sec. 502. Contracts with, and grants to, urban Indian organizations.

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

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

`Sec. 505. Evaluations; renewals.

`Sec. 506. Other contract and grant requirements.

`Sec. 507. Reports and records.

`Sec. 508. Limitation on contract authority.

`Sec. 509. Facilities.

`Sec. 510. Division of urban Indian health.

`Sec. 511. Grants for alcohol and substance abuse-related services.

`Sec. 512. Treatment of certain demonstration projects.

`Sec. 513. Urban NIAAA transferred programs.

`Sec. 514. Consultation with urban Indian organizations.

`Sec. 515. Urban youth treatment center demonstration.

`Sec. 516. Use of Federal Government facilities and sources of supply.

`Sec. 517. Grants for diabetes prevention, treatment, and control.

`Sec. 518. Community health representatives.

`Sec. 519. Effective date.

`Sec. 520. Eligibility for services.

`Sec. 521. Authorization of appropriations.

`TITLE VI--ORGANIZATIONAL IMPROVEMENTS

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

`Sec. 602. Automated management information system.

`Sec. 603. Authorization of appropriations.

`TITLE VII--BEHAVIORAL HEALTH PROGRAMS

`Sec. 701. Behavioral health prevention and treatment services.

`Sec. 702. Memoranda of agreement with the Department of the Interior.

`Sec. 703. Comprehensive behavioral health prevention and treatment program.

`Sec. 704. Mental health technician program.

`Sec. 705. Licensing requirement for mental health care workers.

`Sec. 706. Indian women treatment programs.

`Sec. 707. Indian youth program.

`Sec. 708. Inpatient and community-based mental health facilities design, construction, and staffing.

`Sec. 709. Training and community education.

`Sec. 710. Behavioral health program.

`Sec. 711. Fetal alcohol disorder programs.

`Sec. 712. Child sexual abuse and prevention treatment programs.

`Sec. 713. Behavioral health research.

`Sec. 714. Definitions.

`Sec. 715. Authorization of appropriations.

`TITLE VIII--MISCELLANEOUS

`Sec. 801. Reports.

`Sec. 802. Regulations.

`Sec. 803. Plan of implementation.

`Sec. 804. Availability of funds.

`Sec. 805. Limitation on use of funds appropriated to the Indian health Service.

`Sec. 806. Eligibility of California Indians.

`Sec. 807. Health services for ineligible persons.

`Sec. 808. Reallocation of base resources.

`Sec. 809. Results of demonstration projects.

`Sec. 810. Provision of services in Montana.

`Sec. 811. Moratorium.

`Sec. 812. Tribal employment.

`Sec. 813. Severability provisions.

`Sec. 814. Appropriations; availability.

`Sec. 815. Authorization of appropriations.

`SEC. 2. DECLARATION OF NATIONAL INDIAN HEALTH POLICY.

`Congress hereby declares that it is the policy of this Nation, in fulfillment of its special trust responsibilities and legal obligations to Indians--

`(1) to assure the highest possible health status for Indians and to provide all resources necessary to effect that policy;

`(2) to raise the health status of Indians by the year 2010 to at least the levels set forth in the goals contained within the Healthy People 2010 or successor objectives;

`(3) to the greatest extent possible, to allow Indians to set their own health care priorities and establish goals that reflect their unmet needs;

`(4) to increase the proportion of all degrees in the health professions and allied and associated health professions awarded to Indians so that the proportion of Indian health professionals in each Service Area is raised to at least the level of that of the general population;

`(5) to require meaningful consultation with Indian Tribes, Tribal Organizations, and Urban Indian Organizations to implement this Act and the national policy of Indian self-determination; and

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

`SEC. 3. DEFINITIONS.

`For purposes of this Act:

`(1) The term `accredited and accessible' means on or near a reservation and accredited by a national or regional organization with accrediting authority.

`(2) The term `Area Office' means an administrative entity including a program office, within the Service through which services and funds are provided to the Service Units within a defined geographic area.

`(3) The term `Assistant Secretary' means the Assistant Secretary of Indian Health.

`(4) The term `behavioral health' means the blending of substance (alcohol, drugs, inhalants, and tobacco) abuse and mental illness prevention and treatment, for the purpose of providing comprehensive services. This definition can include the joint development of substance abuse and mental illness treatment planning and coordinated case management using a multidisciplinary approach.

`(5) The term `California Indians' shall mean those Indians who are eligible for health services of the Service pursuant to section 806.

`(6) The term `community college' means--

`(A) a tribal college or university, or

`(B) a junior or community college.

`(7) The term `contract health service' means health services provided at the expense of the Service or a Tribal Health Program by public or private medical providers or hospitals, other than the Service Unit or the Tribal Health Program at whose expense the services are provided.

`(8) The term `Department' means, unless otherwise designated, the Department of Health and Human Services.

`(9) The term `disease prevention' means the reduction, limitation, and prevention of disease and its complications and reduction in the consequences of disease, including--

`(A) controlling--

`(i) development of diabetes;

`(ii) high blood pressure;

`(iii) infectious agents;

`(iv) injuries;

`(v) occupational hazards and disabilities;

`(vi) sexually transmittable diseases; and

`(vii) toxic agents; and

`(B) providing--

`(i) fluoridation of water; and

`(ii) immunizations.

`(10) The term `health profession' means allopathic medicine, family medicine, internal medicine, pediatrics, geriatric medicine, obstetrics and gynecology, podiatric medicine, nursing, public health nursing, advanced practice nursing, dentistry, psychiatry, osteopathy, optometry, pharmacy, psychology, public health, social work, marriage and family therapy, chiropractic medicine, environmental health and engineering, allied health professions, naturopathic medicine and any other health profession.

`(11) The term `health promotion' means--

`(A) fostering social, economic, environmental, and personal factors conducive to health, including raising public awareness about health matters and enabling the people to cope with health problems by increasing their knowledge and providing them with valid information;

`(B) encouraging adequate and appropriate diet, exercise, and sleep;

`(C) promoting education and work in conformity with physical and mental capacity;

`(D) making available suitable housing, safe water, and sanitary facilities;

`(E) improving the physical, economic, cultural, psychological, and social environment;

`(F) promoting adequate opportunity for spiritual, religious, and Traditional Health Care Practices; and

`(G) providing adequate and appropriate programs, including, but not limited to--

`(i) abuse prevention (mental and physical);

`(ii) community health;

`(iii) community safety;

`(iv) consumer health education;

`(v) diet and nutrition;

`(vi) immunization and other prevention of communicable diseases, including HIV/AIDS;

`(vii) environmental health;

`(viii) exercise and physical fitness;

`(ix) avoidance of fetal alcohol disorders;

`(x) first aid and CPR education;

`(xi) human growth and development;

`(xii) injury prevention and personal safety;

`(xiii) behavioral health;

`(xiv) monitoring of disease indicators between health care provider visits, through appropriate means, including Internet-based health care management systems;

`(xv) personal health and wellness practices;

`(xvi) personal capacity building;

`(xvii) prenatal, pregnancy, and infant care;

`(xviii) psychological well-being;

`(xix) reproductive health and family planning;

`(xx) safe and adequate water;

`(xxi) safe housing relative to eliminating, reducing, or preventing contaminants which create unhealthy housing conditions;

`(xxii) safe work environments;

`(xxiii) stress control;

`(xxiv) substance abuse;

`(xxv) sanitary facilities;

`(xxvi) sudden infant death syndrome prevention;

`(xxvii) tobacco use cessation and reduction;

`(xxviii) violence prevention; and

`(xxix) such other activities identified by the Service, a Tribal Health Program, or an Urban Indian Organization, to promote achievement of any of the objectives described in section 3(2).

`(12) The term `Indian' unless otherwise designated, means any person who is a member of an Indian Tribe or is eligible for health services under section 806, except that, for the purpose of sections 102 and 103, the term also means any individual who--

(A)(i) irrespective of whether the individual lives on or near a reservation, is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside; or

(ii) is a descendant, in the first or second degree, of any such member;

(B) is an Eskimo or Aleut or other Alaska Native;

(D) is determined to be in Indian under regulations promulgated by the Secretary.

`(13) The term `Indian Health Program' means--

`(A) any health program administered directly by the Service;

`(B) any Tribal Health Program; or

`(C) any Indian Tribe or Tribal Organization to which the Secretary provides funding pursuant to section 23 of the Act of April 30, 1908 (25 U.S.C. 47), commonly known as the `Buy Indian Act'.

`(14) The term `Indian Tribe' has the meaning given the term in the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.).

`(15) The term `junior or community college' has the meaning given the term by section 312(e) of the Higher Education Act of 1965 (20 U.S.C. 1058(e)).

`(16) The term `reservation' means any federally recognized Indian Tribe's reservation, Pueblo, or colony, including former reservations in Oklahoma, Indian allotments, and Alaska Native Regions established pursuant to the Alaska Native Claims Settlement Act (25 U.S.C. 1601 et seq.).

`(17) The term `Secretary', unless otherwise designated, means the Secretary of Health and Human Services.

`(18) The term `Service' means the Indian Health Service.

`(19) The term `Service Area' means the geographical area served by each Area Office.

`(20) The term `Service Unit' means an administrative entity of the Service, or a Tribal Health Program through which services are provided, directly or by contract, to eligible Indians within a defined geographic area.

`(21) The term `telehealth' has the meaning given the term in section 330K(a) of the Public Health Service Act (42 U.S.C. 254c-16(a)).

`(22) The term `telemedicine' means a telecommunications link to an end user through the use of eligible equipment that electronically links health professionals or patients and health professionals at separate sites in order to exchange health care information in audio, video, graphic, or other format for the purpose of providing improved health care services.

`(23) The term `tribal college or university' has the meaning given the term in section 316(b)(3) of the Higher Education Act (20 U.S.C. 1059c(b)(3)).

`(24) The term `Tribal Health Program' means an Indian Tribe or Tribal Organization that operates any health program, service, function, activity, or facility funded, in whole or part, by the Service through, or provided for in, a Funding Agreement with the Service under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.).

`(25) The term `Tribal Organization' has the meaning given the term in the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.).

`(26) The term `Urban Center' means any community which has a sufficient Urban Indian population with unmet health needs to warrant assistance under title V of this Act, as determined by the Secretary.

`(27) The term `Urban Indian' means any individual who resides in an Urban Center and who meets 1 or more of the following criteria:

`(A) Irrespective of whether the individual lives on or near a reservation, the individual is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those tribes, bands, or groups that are recognized by the States in which they reside, or who is a descendant in the first or second degree of any such member.

`(B) The individual is an Eskimo, Aleut, or other Alaskan Native.

`(C) The individual is considered by the Secretary of the Interior to be an Indian for any purpose.

`(D) The individual is determined to be an Indian under regulations promulgated by the Secretary.

`(28) The term `Urban Indian Organization' means a nonprofit corporate body that (A) is situated in an Urban Center; (B) is governed by an Urban Indian-controlled board of directors; (C) provides for the participation of all interested Indian groups and individuals; and (D) is capable of legally cooperating with other public and private entities for the purpose of performing the activities described in section 503(a).

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

`SEC. 101. PURPOSE.

`The purpose of this title is to increase, to the maximum extent feasible, the number of Indians entering the health professions and providing health services, and to assure an optimum supply of health professionals to the Indian Health Programs and Urban Indian Organizations involved in the provision of health services to Indians.

`SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM FOR INDIANS.

`(a) IN GENERAL- The Secretary, acting through the Service, shall make funds available to public or nonprofit private health or educational entities, Tribal Health Programs, or Urban Indian Organizations to assist such entities in meeting the costs of--

`(1) identifying Indians with a potential for education or training in the health professions and encouraging and assisting them--

`(A) to enroll in courses of study in such health professions; or

`(B) if they are not qualified to enroll in any such courses of study, to undertake such postsecondary education or training as may be required to qualify them for enrollment;

`(2) publicizing existing sources of financial aid available to Indians enrolled in any course of study referred to in paragraph (1) or who are undertaking training necessary to qualify them to enroll in any such course of study; or

`(3) establishing other programs which the Secretary determines will enhance and facilitate the enrollment of Indians in, and the subsequent pursuit and completion by them of, courses of study referred to in paragraph (1).

`(b) FUNDING-

`(1) APPLICATION- The Secretary shall not make a grant under this section unless an application has been submitted to, and approved by, the Secretary. Such application shall be in such form, submitted in such manner, and contain such information, as the Secretary shall by regulation prescribe pursuant to this Act. The Secretary shall give a preference to applications submitted by Tribal Health Programs or Urban Indian Organizations.

`(2) AMOUNT OF GRANTS; PAYMENT- The amount of a grant under this section shall be determined by the Secretary. Payments pursuant to this section may be made in advance or by way of reimbursement, and at such intervals and on such conditions as provided for in regulations issued pursuant to this Act. To the extent not otherwise prohibited by law, funding commitments shall be for 3 years, as provided in regulations issued pursuant to this Act.

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

`(a) SCHOLARSHIPS AUTHORIZED- The Secretary, acting through the Service, shall provide scholarships to Indians who--

`(1) have successfully completed their high school education or high school equivalency; and

`(2) have demonstrated the potential to successfully complete courses of study in the health professions.

`(b) PURPOSES- Scholarship grants provided pursuant to this section shall be for the following purposes:

`(1) Compensatory preprofessional education of any recipient, such scholarship not to exceed 2 years on a full-time basis (or the part-time equivalent thereof, as determined by the Secretary pursuant to regulations issued under this Act).

`(2) Pregraduate education of any recipient leading to a baccalaureate degree in an approved course of study preparatory to a field of study in a health profession, such scholarship not to exceed 4 years. An extension of up to 2 years (or the part-time equivalent thereof, as determined by the Secretary pursuant to regulations issued pursuant to this Act) may be approved.

`(c) OTHER CONDITIONS- Scholarships under this section--

`(1) may cover costs of tuition, books, transportation, board, and other necessary related expenses of a recipient while attending school;

`(2) shall not be denied solely on the basis of the applicant's scholastic achievement if such applicant has been admitted to, or maintained good standing at, an accredited institution; and

`(3) shall not be denied solely by reason of such applicant's eligibility for assistance or benefits under any other Federal program.

`SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS.

`(a) IN GENERAL-

`(2) DETERMINATION BY SECRETARY- The Secretary, acting through the Service, shall determine--

`(A) who shall receive scholarship grants under subsection (a); and

`(B) the distribution of the scholarships among health professions on the basis of the relative needs of Indians for additional service in the health professions.

`(3) CERTAIN DELEGATION NOT ALLOWED- The administration of this section shall be a responsibility of the Assistant Secretary and shall not be delegated in a contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.)

`(b) ACTIVE DUTY SERVICE OBLIGATION-

`(1) OBLIGATION MET- The active duty service obligation under a written contract with the Secretary under section 338A of the Public Health Service Act (42 U.S.C. 254l) that an Indian has entered into under that section shall, if that individual is a recipient of an Indian Health Scholarship, be met in full-time practice on an equivalent year-for-year obligation, by service in one or more of the following:

`(A) In an Indian Health Program.

`(B) In a program assisted under title V of this Act.

`(C) In the private practice of the applicable profession if, as determined by the Secretary, in accordance with guidelines promulgated by the Secretary, such practice is situated in a physician or other health professional shortage area and addresses the health care needs of a substantial number of Indians.

`(D) In a teaching capacity in a tribal college or university program (or a related health profession program) if, as determined by the Secretary, the health service provided to Indians would not decrease.

`(2) OBLIGATION DEFERRED- At the request of any individual who has entered into a contract referred to in paragraph (1) and who receives a degree in medicine (including osteopathic or allopathic medicine), dentistry, optometry, podiatry, or pharmacy, the Secretary shall defer the active duty service obligation of that individual under that contract, in order that such individual may complete any internship, residency, or other advanced clinical training that is required for the practice of that health profession, for an appropriate period (in years, as determined by the Secretary), subject to the following conditions:

`(A) No period of internship, residency, or other advanced clinical training shall be counted as satisfying any period of obligated service under this subsection.

`(B) The active duty service obligation of that individual shall commence not later than 90 days after the completion of that advanced clinical training (or by a date specified by the Secretary).

`(C) The active duty service obligation will be served in the health profession of that individual in a manner consistent with paragraph (1).

`(D) A recipient of a scholarship under this section may, at the election of the recipient, meet the active duty service obligation described in paragraph (1) by service in a program specified under that paragraph that--

`(i) is located on the reservation of the Indian Tribe in which the recipient is enrolled; or

`(ii) serves the Indian Tribe in which the recipient is enrolled.

`(3) PRIORITY WHEN MAKING ASSIGNMENTS- Subject to paragraph (2), the Secretary, in making assignments of Indian Health Scholarship recipients required to meet the active duty service obligation described in paragraph (1), shall give priority to assigning individuals to service in those programs specified in paragraph (1) that have a need for health professionals to provide health care services as a result of individuals having breached contracts entered into under this section.

`(c) PART-TIME STUDENTS- In the case of an individual receiving a scholarship under this section who is enrolled part-time in an approved course of study part-time equivalent of 4 years, as determined by the Area Office--

`(1) the period of obligated service described in subsection (b)(1) shall be equal to the greater of--

`(A) the part-time equivalent of 1 year for each year for which the individual was provided a scholarship (as determined by the Area Office); or

`(B) 2 years; and

`(d) BREACH OF CONTRACT-

`(1) SPECIFIED BREACHES- An individual shall be liable to the United States for the amount which has been paid to the individual, or on behalf of the individual, under a contract entered into with the Secretary under this section on or after the date of the enactment of the Indian Health Care Improvement Act Amendments of 2006 if that individual--

`(A) fails to maintain an acceptable level of academic standing in the educational institution in which he or she is enrolled (such level determined by the educational institution under regulations of the Secretary);

`(B) is dismissed from such educational institution for disciplinary reasons;

`(C) voluntarily terminates the training in such an educational institution for which he or she is provided a scholarship under such contract before the completion of such training; or

`(D) fails to accept payment, or instructs the educational institution in which he or she is enrolled not to accept payment, in whole or in part, of a scholarship under such contract, in lieu of any service obligation arising under such contract.

`(3) CANCELLATION UPON DEATH OF RECIPIENT- Upon the death of an individual who receives an Indian Health Scholarship, any outstanding obligation of that individual for service or payment that relates to that scholarship shall be canceled.

`(4) WAIVERS AND SUSPENSIONS-

`(A) IN GENERAL- The Secretary shall provide for the partial or total waiver or suspension of any obligation of service or payment of a recipient of an Indian Health Scholarship if the Secretary, in consultation with the affected Area Office, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, determines that--

`(i) it is not possible for the recipient to meet that obligation or make that payment would result in extreme hardship to the recipient; or

`(ii) requiring that recipient to meet that obligation or make that payment would result in extreme hardship to the recipient; or

`(iii) the enforcement of the requirement to meet the obligation or make the payment would be unconscionable.

`(B) FACTORS FOR CONSIDERATION- Before waiving or suspending an obligation of service or payment under subparagraph (A), the Secretary may take into consideration whether the obligation may be satisfied in a teaching capacity at a tribal college or university nursing program under subsection (b)(1)(D).

`(5) EXTREME HARDSHIP- Notwithstanding any other provision of law, in any case of extreme hardship or for other good cause shown, the Secretary may waive, in whole or in part, the right of the United States to recover funds made available under this section.

`(6) BANKRUPTCY- Notwithstanding any other provision of law, with respect to a recipient of an Indian Health Scholarship, no obligation for payment may be released by a discharge in bankruptcy under title 11, United States Code, unless that discharge is granted after the expiration of the 5-year period beginning on the initial date on which that payment is due, and only if the bankruptcy court finds that the nondischarge of the obligation would be unconscionable.

`SEC. 105. AMERICAN INDIANS INTO PSYCHOLOGY PROGRAM.

`(a) GRANTS AUTHORIZED- The Secretary, acting through the Service, shall make grants of not more than $300,000 to each of 9 colleges and universities for the purpose of developing and maintaining Indian psychology career recruitment programs as a means of encouraging Indians to enter the mental health field. These programs shall be located at various locations throughout the country to maximize their availability to Indian students and new programs shall be established in different locations from time to time.

`(b) QUENTIN N. BURDICK PROGRAM GRANT- The Secretary shall provide a grant authorized under subsection (a) to develop and maintain a program at the University of North Dakota to be known as the `Quentin N. Burdick American Indians Into Psychology Program'. Such program shall, to the maximum extent feasible, coordinate with the Quentin N. Burdick Indian Health Programs authorized under section 117(b), the Quentin N. Burdick American Indians Into Nursing Program authorized under section 115(e), and existing university research and communications networks.

`(c) REGULATIONS- The Secretary shall issue regulations pursuant to this Act for the competitive awarding of funds provided under this section.

`(d) CONDITIONS OF GRANT- Applicants under this section shall agree to provide a program which, at a minimum--

`(1) provides outreach and recruitment for health professions to Indian communities including elementary, secondary, and accredited and accessible community colleges that will be served by the program;

`(2) incorporates a program advisory board comprised of representatives from the tribes and communities that will be served by the program;

`(3) provides summer enrichment programs to expose Indian students to the various fields of psychology through research, clinical, and experimental activities;

`(4) provides stipends to undergraduate and graduate students to pursue a career in psychology;

`(5) develops affiliation agreements with tribal colleges and universities, the Service, university affiliated programs, and other appropriate accredited and accessible entities to enhance the education of Indian students;

`(6) to the maximum extent feasible, uses existing university tutoring, counseling, and student support services; and

`(7) to the maximum extent feasible, employs qualified Indians in the program.

`(e) ACTIVE DUTY SERVICE REQUIREMENT- The active duty service obligation prescribed under section 338C of the Public Health Service Act (42 U.S.C. 254m) shall be met by each graduate who receives a stipend described in subsection (d)(4) that is funded under this section. Such obligation shall be met by service--

`(1) in an Indian Health Program;

`(2) in a program assisted under title V of this Act; or

`(3) in the private practice of psychology if, as determined by the Secretary, in accordance with guidelines promulgated by the Secretary, such practice is situated in a physician or other health professional shortage area and addresses the health care needs of a substantial number of Indians.

`SEC. 106. SCHOLARSHIP PROGRAMS FOR INDIAN TRIBES.

`(a) IN GENERAL-

`(1) GRANTS AUTHORIZED- The Secretary, acting through the Service, shall make grants to Tribal Health Programs for the purpose of providing scholarships for Indians to serve as health professionals in Indian communities.

`(2) AMOUNT- Amounts available under paragraph (1) for any fiscal year shall not exceed 5 percent of the amounts available for each fiscal year for Indian Health Scholarships under section 104.

`(3) APPLICATION- An application for a grant under paragraph (1) shall be in such form and contain such agreements, assurances, and information as consistent with this section.

`(b) REQUIREMENTS-

`(1) IN GENERAL- A Tribal Health Program receiving funds under subsection (a) shall provide scholarships to Indians in accordance with the requirements of this section.

`(2) COSTS- With respect to costs of providing any scholarship pursuant to subsection (a)--

`(A) 80 percent of the costs of the scholarship shall be paid from the funds made available pursuant to subsection (a)(1) provided to the Tribal Health Program; and

`(B) 20 percent of such costs may be paid from any other source of funds.

`(c) COURSE OF STUDY- A Tribal Health Program shall provide scholarships under this section only to Indians enrolled or accepted for enrollment in a course of study (approved by the Secretary) in one of the health professions contemplated by this Act.

`(d) CONTRACT- In providing scholarships under subsection (b), the Secretary and the Tribal Health Program shall enter into a written contract with each recipient of such scholarship. Such contract shall--

`(1) obligate such recipient to provide service in an Indian Health Program or Urban Indian Organization, in the same Service Area where the Tribal Health Program providing the scholarship is located, for--

`(A) a number of years for which the scholarship is provided (or the part-time equivalent thereof, as determined by the Secretary), or for a period of 2 years, whichever period is greater; or

`(B) such greater period of time as the recipient and the Tribal Health Program may agree;

`(2) provide that the amount of the scholarship--

`(A) may only be expended for--

`(i) tuition expenses, other reasonable educational expenses, and reasonable living expenses incurred in attendance at the educational institution; and

`(ii) payment to the recipient of a monthly stipend of not more than the amount authorized by section 338(g)(1)(B) of the Public Health Service Act (42 U.S.C. 254m(g)(1)(B)), such amount to be reduced pro rata (as determined by the Secretary) based on the number of hours such student is enrolled; and may not exceed, for any year of attendance for which the scholarship is provided, the total amount required for the year for the purposes authorized in this clause; and

`(B) may not exceed, for any year of attendance for which the scholarship is provided, the total amount required for the year for the purposes authorized in subparagraph (A);

`(3) require the recipient of such scholarship to maintain an acceptable level of academic standing as determined by the educational institution in accordance with regulations issued pursuant to this Act; and

`(4) require the recipient of such scholarship to meet the educational and licensing requirements appropriate to each health profession.

`(e) BREACH OF CONTRACT-

`(1) SPECIFIC BREACHES- An individual who has entered into a written contract with the Secretary and a Tribal Health Program under subsection (d) shall be liable to the United States for the Federal share of the amount which has been paid to him or her, or on his or her behalf, under the contract if that individual--

`(A) fails to maintain an acceptable level of academic standing in the educational institution in which he or she is enrolled (such level as determined by the educational institution under regulations of the Secretary);

`(B) is dismissed from such educational institution for disciplinary reasons;

`(C) voluntarily terminates the training in such an educational institution for which he or she is provided a scholarship under such contract before the completion of such training; or

`(4) INFORMATION- The Secretary may carry out this subsection on the basis of information received from Tribal Health Programs involved or on the basis of information collected through such other means as the Secretary deems appropriate.

`(f) RELATION TO SOCIAL SECURITY ACT- The recipient of a scholarship under this section shall agree, in providing health care pursuant to the requirements herein--

`(1) not to discriminate against an individual seeking care on the basis of the ability of the individual to pay for such care or on the basis that payment for such care will be made pursuant to a program established in title XVIII of the Social Security Act or pursuant to the programs established in title XIX or title XXI of such Act; and

`(2) to accept assignment under section 1842(b)(3)(B)(ii) of the Social Security Act for all services for which payment may be made under part B of title XVIII of such Act, and to enter into an appropriate agreement with the State agency that administers the State plan for medical assistance under title XIX, or the State child health plan under title XXI, of such Act to provide service to individuals entitled to medical assistance or child health assistance, respectively, under the plan.

`(g) CONTINUANCE OF FUNDING- The Secretary shall make payments under this section to a Tribal Health Program for any fiscal year subsequent to the first fiscal year of such payments unless the Secretary determines that, for the immediately preceding fiscal year, the Tribal Health Program has not complied with the requirements of this section.

`SEC. 107. INDIAN HEALTH SERVICE EXTERN PROGRAMS.

`(a) EMPLOYMENT PREFERENCE- Any individual who receives a scholarship pursuant to section 104 or 106 shall be given preference for employment in the Service, or may be employed by a Tribal Health Program or an Urban Indian Organization, or other agencies of the Department as available, during any nonacademic period of the year.

`(b) NOT COUNTED TOWARD ACTIVE DUTY SERVICE OBLIGATION- Periods of employment pursuant to this subsection shall not be counted in determining fulfillment of the service obligation incurred as a condition of the scholarship.

`(c) TIMING; LENGTH OF EMPLOYMENT- Any individual enrolled in a program, including a high school program, authorized under section 102(a) may be employed by the Service or by a Tribal Health Program or an Urban Indian Organization during any nonacademic period of the year. Any such employment shall not exceed 120 days during any calendar year.

`(d) NONAPPLICABILITY OF COMPETITIVE PERSONNEL SYSTEM- Any employment pursuant to this section shall be made without regard to any competitive personnel system or agency personnel limitation and to a position which will enable the individual so employed to receive practical experience in the health profession in which he or she is engaged in study. Any individual so employed shall receive payment for his or her services comparable to the salary he or she would receive if he or she were employed in the competitive system. Any individual so employed shall not be counted against any employment ceiling affecting the Service or the Department.

`SEC. 108. CONTINUING EDUCATION ALLOWANCES.

`In order to encourage health professionals, including community health representatives and emergency medical technicians, to join or continue in an Indian Health Program or an Urban Indian Organization and to provide their services in the rural and remote areas where a significant portion of Indians reside, the Secretary, acting through the Service, may provide allowances to health professionals employed in an Indian Health Program or an Urban Indian Organization to enable them for a period of time each year prescribed by regulation of the Secretary to take leave of their duty stations for professional consultation and refresher training courses.

`SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PROGRAM.

`(a) IN GENERAL- Under the authority of the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'), the Secretary, acting through the Service, shall maintain a Community Health Representative Program under which Indian Health Programs--

`(1) provide for the training of Indians as community health representatives; and

`(2) use such community health representatives in the provision of health care, health promotion, and disease prevention services to Indian communities.

`(b) DUTIES- The Community Health Representative Program of the Service, shall--

`(1) provide a high standard of training for community health representatives to ensure that the community health representatives provide quality health care, health promotion, and disease prevention services to the Indian communities served by the Program;

`(2) in order to provide such training, develop and maintain a curriculum that--

`(A) combines education in the theory of health care with supervised practical experience in the provision of health care; and

`(B) provides instruction and practical experience in health promotion and disease prevention activities, with appropriate consideration given to lifestyle factors that have an impact on Indian health status, such as alcoholism, family dysfunction, and poverty;

`(3) maintain a system which identifies the needs of community health representatives for continuing education in health care, health promotion, and disease prevention, and develop programs that meet the needs for continuing education;

`(4) maintain a system that provides close supervision of Community Health Representatives;

`(5) maintain a system under which the work of Community Health Representatives is reviewed and evaluated; and

`(6) promote Traditional Health Care Practices of the Indian Tribes served consistent with the Service standards for the provision of health care, health promotion, and disease prevention.

`SEC. 110. INDIAN HEALTH SERVICE LOAN REPAYMENT PROGRAM.

`(a) ESTABLISHMENT- The Secretary, acting through the Service, shall establish and administer a program to be known as the Service Loan Repayment Program (hereinafter referred to as the `Loan Repayment Program') in order to ensure an adequate supply of trained health professionals necessary to maintain accreditation of, and provide health care services to Indians through, Indian Health Programs and Urban Indian Organizations.

`(b) ELIGIBLE INDIVIDUALS- To be eligible to participate in the Loan Repayment Program, an individual must--

`(1)(A) be enrolled--

`(ii) in an approved graduate training program in a health profession; or

`(B) have--

`(i) a degree in a health profession; and

`(ii) a license to practice a health profession;

`(2)(A) be eligible for, or hold, an appointment as a commissioned officer in the Regular or Reserve Corps of the Public Health Service;

`(B) be eligible for selection for civilian service in the Regular or Reserve Corps of the Public Health Service;

`(C) meet the professional standards for civil service employment in the Service; or

`(D) be employed in an Indian Health Program or Urban Indian Organization without a service obligation; and

`(3) submit to the Secretary an application for a contract described in subsection (e).

In the administration of this section, naturopathic medicine is included among the other health professions.

`(c) APPLICATION-

`(2) CLEAR LANGUAGE- The application form, contract form, and all other information furnished by the Secretary under this section shall be written in a manner calculated to be understood by the average individual applying to participate in the Loan Repayment Program.

`(3) TIMELY AVAILABILITY OF FORMS- The Secretary shall make such application forms, contract forms, and other information available to individuals desiring to participate in the Loan Repayment Program on a date sufficiently early to ensure that such individuals have adequate time to carefully review and evaluate such forms and information.

`(d) PRIORITIES-

`(1) LIST- Consistent with subsection (k), the Secretary shall annually--

`(A) identify the positions in each Indian Health Program or Urban Indian Organization for which there is a need or a vacancy; and

`(B) rank those positions in order of priority.

`(2) APPROVALS- Notwithstanding the priority determined under paragraph (1), the Secretary, in determining which applications under the Loan Repayment Program to approve (and which contracts to accept), shall--

`(A) give first priority to applications made by individual Indians; and

`(B) after making determinations on all applications submitted by individual Indians as required under subparagraph (A), give priority to--

`(i) individuals recruited through the efforts of an Indian Health Program or Urban Indian Organization; and

`(ii) other individuals based on the priority rankings under paragraph (1).

`(e) RECIPIENT CONTRACTS-

`(1) CONTRACT REQUIRED- An individual becomes a participant in the Loan Repayment Program only upon the Secretary and the individual entering into a written contract described in paragraph (2).

`(2) CONTENTS OF CONTRACT- The written contract referred to in this section between the Secretary and an individual shall contain--

`(A) an agreement under which--

`(i) subject to subparagraph (C), the Secretary agrees--

`(I) to pay loans on behalf of the individual in accordance with the provisions of this section; and

`(II) to accept (subject to the availability of appropriated funds for carrying out this section) the individual into the Service or place the individual with a Tribal Health Program or Urban Indian Organization as provided in clause (ii)(III); and

`(ii) subject to subparagraph (C), the individual agrees--

`(I) to accept loan payments on behalf of the individual;

`(II) in the case of an individual described in subsection (b)(1)--

`(aa) to maintain enrollment in a course of study or training described in subsection (b)(1)(A) until the individual completes the course of study or training; and

`(bb) while enrolled in such course of study or training, to maintain an acceptable level of academic standing (as determined under regulations of the Secretary by the educational institution offering such course of study or training); and

`(III) to serve for a time period (hereinafter in this section referred to as the `period of obligated service') equal to 2 years or such longer period as the individual may agree to serve in the full-time clinical practice of such individual's profession in an Indian Health Program or Urban Indian Organization to which the individual may be assigned by the Secretary;

`(B) a provision permitting the Secretary to extend for such longer additional periods, as the individual may agree to, the period of obligated service agreed to by the individual under subparagraph (A)(ii)(III);

`(C) a provision that any financial obligation of the United States arising out of a contract entered into under this section and any obligation of the individual which is conditioned thereon is contingent upon funds being appropriated for loan repayments under this section;

`(E) such other statements of the rights and liabilities of the Secretary and of the individual, not inconsistent with this section.

`(f) DEADLINE FOR DECISION ON APPLICATION- The Secretary shall provide written notice to an individual within 21 days on--

`(1) the Secretary's approval, under subsection (e)(1), of the individual's participation in the Loan Repayment Program, including extensions resulting in an aggregate period of obligated service in excess of 4 years; or

`(2) the Secretary's disapproval of an individual's participation in such Program.

`(g) PAYMENTS-

`(1) IN GENERAL- A loan repayment provided for an individual under a written contract under the Loan Repayment Program shall consist of payment, in accordance with paragraph (2), on behalf of the individual of the principal, interest, and related expenses on government and commercial loans received by the individual regarding the undergraduate or graduate education of the individual (or both), which loans were made for--

`(A) tuition expenses;

`(B) all other reasonable educational expenses, including fees, books, and laboratory expenses, incurred by the individual; and

`(C) reasonable living expenses as determined by the Secretary.

`(2) AMOUNT- For each year of obligated service that an individual contracts to serve under subsection (e), the Secretary may pay up to $35,000 or an amount equal to the amount specified in section 338B(g)(2)(A) of the Public Health Service Act, whichever is more, on behalf of the individual for loans described in paragraph (1). In making a determination of the amount to pay for a year of such service by an individual, the Secretary shall consider the extent to which each such determination--

`(A) affects the ability of the Secretary to maximize the number of contracts that can be provided under the Loan Repayment Program from the amounts appropriated for such contracts;

`(B) provides an incentive to serve in Indian Health Programs and Urban Indian Organizations with the greatest shortages of health professionals; and

`(C) provides an incentive with respect to the health professional involved remaining in an Indian Health Program or Urban Indian Organization with such a health professional shortage, and continuing to provide primary health services, after the completion of the period of obligated service under the Loan Repayment Program.

`(3) TIMING- Any arrangement made by the Secretary for the making of loan repayments in accordance with this subsection shall provide that any repayments for a year of obligated service shall be made no later than the end of the fiscal year in which the individual completes such year of service.

`(4) REIMBURSEMENTS FOR TAX LIABILITY- For the purpose of providing reimbursements for tax liability resulting from payments under paragraph (2) on behalf of an individual, the Secretary--

`(A) in addition to such payments, may make payments to the individual in an amount not less than 20 percent and not more than 39 percent of the total amount of loan repayments made for the taxable year involved; and

`(B) may make such additional payments as the Secretary determines to be appropriate with respect to such purpose.

`(5) PAYMENT SCHEDULE- The Secretary may enter into an agreement with the holder of any loan for which payments are made under the Loan Repayment Program to establish a schedule for the making of such payments.

`(h) EMPLOYMENT CEILING- Notwithstanding any other provision of law, individuals who have entered into written contracts with the Secretary under this section shall not be counted against any employment ceiling affecting the Department while those individuals are undergoing academic training.

`(i) RECRUITMENT- The Secretary shall conduct recruiting programs for the Loan Repayment Program and other Service manpower programs at educational institutions training health professionals or specialists identified in subsection (a).

`(j) APPLICABILITY OF LAW- Section 214 of the Public Health Service Act (42 U.S.C. 215) shall not apply to individuals during their period of obligated service under the Loan Repayment Program.

`(k) ASSIGNMENT OF INDIVIDUALS- The Secretary, in assigning individuals to serve in Indian Health Programs or Urban Indian Organizations pursuant to contracts entered into under this section, shall--

`(1) ensure that the staffing needs of Tribal Health Programs and Urban Indian Organizations receive consideration on an equal basis with programs that are administered directly by the Service; and

`(2) give priority to assigning individuals to Indian Health Programs and Urban Indian Organizations that have a need for health professionals to provide health care services as a result of individuals having breached contracts entered into under this section.

`(l) BREACH OF CONTRACT-

`(1) SPECIFIC BREACHES- An individual who has entered into a written contract with the Secretary under this section and has not received a waiver under subsection (m) shall be liable, in lieu of any service obligation arising under such contract, to the United States for the amount which has been paid on such individual's behalf under the contract if that individual--

`(A) is enrolled in the final year of a course of study and--

`(i) fails to maintain an acceptable level of academic standing in the educational institution in which he or she is enrolled (such level determined by the educational institution under regulations of the Secretary);

`(ii) voluntarily terminates such enrollment; or

`(iii) is dismissed from such educational institution before completion of such course of study; or

`(B) is enrolled in a graduate training program and fails to complete such training program.

`(2) OTHER BREACHES; FORMULA FOR AMOUNT OWED- If, for any reason not specified in paragraph (1), an individual breaches his or her written contract under this section by failing either to begin, or complete, such individual's period of obligated service in accordance with subsection (e)(2), the United States shall be entitled to recover from such individual an amount to be determined in accordance with the following formula: A=3Z(t-s/t) in which--

`(A) `A' is the amount the United States is entitled to recover;

`(B) `Z' is the sum of the amounts paid under this section to, or on behalf of, the individual and the interest on such amounts which would be payable if, at the time the amounts were paid, they were loans bearing interest at the maximum legal prevailing rate, as determined by the Secretary of the Treasury;

`(C) `t' is the total number of months in the individual's period of obligated service in accordance with subsection (f); and

`(D) `s' is the number of months of such period served by such individual in accordance with this section.

`(3) DEDUCTIONS IN MEDICARE PAYMENTS- Amounts not paid within such period shall be subject to collection through deductions in Medicare payments pursuant to section 1892 of the Social Security Act.

`(4) TIME PERIOD FOR REPAYMENT- Any amount of damages which the United States is entitled to recover under this subsection shall be paid to the United States within the 1-year period beginning on the date of the breach or such longer period beginning on such date as shall be specified by the Secretary.

`(5) RECOVERY OF DELINQUENCY-

`(A) IN GENERAL- If damages described in paragraph (4) are delinquent for 3 months, the Secretary shall, for the purpose of recovering such damages--

`(i) use collection agencies contracted with by the Administrator of General Services; or

`(ii) enter into contracts for the recovery of such damages with collection agencies selected by the Secretary.

`(B) REPORT- Each contract for recovering damages pursuant to this subsection shall provide that the contractor will, not less than once each 6 months, submit to the Secretary a status report on the success of the contractor in collecting such damages. Section 3718 of title 31, United States Code, shall apply to any such contract to the extent not inconsistent with this subsection.

`(m) WAIVER OR SUSPENSION OF OBLIGATION-

`(1) IN GENERAL- The Secretary shall by regulation provide for the partial or total waiver or suspension of any obligation of service or payment by an individual under the Loan Repayment Program whenever compliance by the individual is impossible or would involve extreme hardship to the individual and if enforcement of such obligation with respect to any individual would be unconscionable.

`(2) CANCELED UPON DEATH- Any obligation of an individual under the Loan Repayment Program for service or payment of damages shall be canceled upon the death of the individual.

`(3) HARDSHIP WAIVER- The Secretary may waive, in whole or in part, the rights of the United States to recover amounts under this section in any case of extreme hardship or other good cause shown, as determined by the Secretary.

`(4) BANKRUPTCY- Any obligation of an individual under the Loan Repayment Program for payment of damages may be released by a discharge in bankruptcy under title 11 of the United States Code only if such discharge is granted after the expiration of the 5-year period beginning on the first date that payment of such damages is required, and only if the bankruptcy court finds that nondischarge of the obligation would be unconscionable.

`(n) REPORT- The Secretary shall submit to the President, for inclusion in each report required to be submitted to Congress under section 801, a report concerning the previous fiscal year which sets forth by Service Area the following:

`(1) A list of the health professional positions maintained by Indian Health Programs and Urban Indian Organizations for which recruitment or retention is difficult.

`(2) The number of Loan Repayment Program applications filed with respect to each type of health profession.

`(3) The number of contracts described in subsection (e) that are entered into with respect to each health profession.

`(4) The amount of loan payments made under this section, in total and by health profession.

`(5) The number of scholarships that are provided under sections 104 and 106 with respect to each health profession.

`(6) The amount of scholarship grants provided under section 104 and 106, in total and by health profession.

`(7) The number of providers of health care that will be needed by Indian Health Programs and Urban Indian Organizations, by location and profession, during the 3 fiscal years beginning after the date the report is filed.

`(8) The measures the Secretary plans to take to fill the health professional positions maintained by Indian Health Programs or Urban Indian Organizations for which recruitment or retention is difficult.

`SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOVERY FUND.

`(b) USE OF FUNDS-

`(1) BY SECRETARY- Amounts in the LRRF may be expended by the Secretary, acting through the Service, to make payments to an Indian Health Program--

`(A) to which a scholarship recipient under section 104 and 106 or a loan repayment program participant under section 110 has been assigned to meet the obligated service requirements pursuant to such sections; and

`(B) that has a need for a health professional to provide health care services as a result of such recipient or participant having breached the contract entered into under section 104, 106, or section 110.

`(2) BY TRIBAL HEALTH PROGRAMS- A Tribal Health Program receiving payments pursuant to paragraph (1) may expend the payments to provide scholarships or recruit and employ, directly or by contract, health professionals to provide health care services.

`(c) INVESTMENT OF FUNDS- The Secretary of the Treasury shall invest such amounts of the LRRF, except for the appropriated funds, as the Secretary determines are not required to meet current withdrawals from the LRRF. Such investments may be made only in interest bearing obligations of the United States. For such purpose, such obligations may be acquired on original issue at the issue price, or by purchase of outstanding obligations at the market price.

`(d) SALE OF OBLIGATIONS- Any obligation acquired by the LRRF may be sold by the Secretary of the Treasury at the market price.

`SEC. 112. RECRUITMENT ACTIVITIES.

`(a) REIMBURSEMENT FOR TRAVEL- The Secretary, acting through the Service, may reimburse health professionals seeking positions with Indian Health Programs or Urban Indian Organizations, including unpaid student volunteers and individuals considering entering into a contract under section 110, and their spouses, for actual and reasonable expenses incurred in traveling to and from their places of residence to an area in which they may be assigned for the purpose of evaluating such area with respect to such assignment.

`(b) RECRUITMENT PERSONNEL- The Secretary, acting through the Service, shall assign one individual in each Area Office to be responsible on a full-time basis for recruitment activities.

`SEC. 113. INDIAN RECRUITMENT AND RETENTION PROGRAM.

`(a) IN GENERAL- The Secretary, acting through the Service, shall fund innovative demonstration projects for a period not to exceed 3 years to enable Tribal Health Programs and Urban Indian Organizations to recruit, place, and retain health professionals to meet their staffing needs.

`(b) ELIGIBLE ENTITIES; APPLICATION- Any Tribal Health Program or Urban Indian Organization may submit an application for funding of a project pursuant to this section.

`SEC. 114. ADVANCED TRAINING AND RESEARCH.

`(a) DEMONSTRATION PROGRAM- The Secretary, acting through the Service, shall establish a demonstration project to enable health professionals who have worked in an Indian Health Program or Urban Indian Organization for a substantial period of time to pursue advanced training or research areas of study for which the Secretary determines a need exists.

`(c) EQUAL OPPORTUNITY FOR PARTICIPATION- Health professionals from Tribal Health Programs and Urban Indian Organizations shall be given an equal opportunity to participate in the program under subsection (a).

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

`(a) GRANTS AUTHORIZED- For the purpose of increasing the number of nurses, nurse midwives, and nurse practitioners who deliver health care services to Indians, the Secretary, acting through the Service, shall provide grants to the following:

`(1) Public or private schools of nursing.

`(2) Tribal colleges or universities.

`(3) Nurse midwife programs and advanced practice nurse programs that are provided by any tribal college or university accredited nursing program, or in the absence of such, any other public or private institutions.

`(b) USE OF GRANTS- Grants provided under subsection (a) may be used for one or more of the following:

`(1) To recruit individuals for programs which train individuals to be nurses, nurse midwives, or advanced practice nurses.

`(2) To provide scholarships to Indians enrolled in such programs that may pay the tuition charged for such program and other expenses incurred in connection with such program, including books, fees, room and board, and stipends for living expenses.

`(3) To provide a program that encourages nurses, nurse midwives, and advanced practice nurses to provide, or continue to provide, health care services to Indians.

`(4) To provide a program that increases the skills of, and provides continuing education to, nurses, nurse midwives, and advanced practice nurses.

`(5) To provide any program that is designed to achieve the purpose described in subsection (a).

`(c) APPLICATIONS- Each application for funding under subsection (a) shall include such information as the Secretary may require to establish the connection between the program of the applicant and a health care facility that primarily serves Indians.

`(d) PREFERENCES FOR GRANT RECIPIENTS- In providing grants under subsection (a), the Secretary shall extend a preference to the following:

`(1) Programs that provide a preference to Indians.

`(2) Programs that train nurse midwives or advanced practice nurses.

`(3) Programs that are interdisciplinary.

`(4) Programs that are conducted in cooperation with a program for gifted and talented Indian students.

`(5) Programs conducted by tribal colleges and universities.

`(e) QUENTIN N. BURDICK PROGRAM GRANT- The Secretary shall provide one of the grants authorized under subsection (a) to establish and maintain a program at the University of North Dakota to be known as the `Quentin N. Burdick American Indians Into Nursing Program'. Such program shall, to the maximum extent feasible, coordinate with the Quentin N. Burdick Indian Health Programs established under section 117(b) and the Quentin N. Burdick American Indians Into Psychology Program established under section 105(b).

`(f) ACTIVE DUTY SERVICE OBLIGATION- The active duty service obligation prescribed under section 338C of the Public Health Service Act (42 U.S.C. 254m) shall be met by each individual who receives training or assistance described in paragraph (1) or (2) of subsection (b) that is funded by a grant provided under subsection (a). Such obligation shall be met by service--

`(1) in the Service;

`(2) in a program of an Indian Tribe or Tribal Organization conducted under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) (including programs under agreements with the Bureau of Indian Affairs);

`(3) in a program assisted under title V of this Act;

`(4) in the private practice of nursing if, as determined by the Secretary, in accordance with guidelines promulgated by the Secretary, such practice is situated in a physician or other health shortage area and addresses the health care needs of a substantial number of Indians; or

`(5) in a teaching capacity in a tribal college or university nursing program (or a related health profession program) if, as determined by the Secretary, health services provided to Indians would not decrease.

`SEC. 116. TRIBAL CULTURAL ORIENTATION.

`(a) CULTURAL EDUCATION OF EMPLOYEES- The Secretary, acting through the Service, shall require that appropriate employees of the Service who serve Indian Tribes in each Service Area receive educational instruction in the history and culture of such Indian Tribes and their relationship to the Service.

`(b) PROGRAM- In carrying out subsection (a), the Secretary shall establish a program which shall, to the extent feasible--

`(1) be developed in consultation with the affected Indian Tribes, Tribal Organizations, and Urban Indian Organizations;

`(2) be carried out through tribal colleges or universities; and

`(3) include instruction in American Indian studies.

`SEC. 117. INMED PROGRAM.

`(a) GRANTS AUTHORIZED- The Secretary, acting through the Service, is authorized to provide grants to colleges and universities for the purpose of maintaining and expanding the Indian health careers recruitment program known as the `Indians Into Medicine Program' (hereinafter in this section referred to as `INMED') as a means of encouraging Indians to enter the health professions.

`(b) QUENTIN N. BURDICK GRANT- The Secretary shall provide one of the grants authorized under subsection (a) to maintain the INMED program at the University of North Dakota, to be known as the `Quentin N. Burdick Indian Health Programs', unless the Secretary makes a determination, based upon program reviews, that the program is not meeting the purposes of this section. Such program shall, to the maximum extent feasible, coordinate with the Quentin N. Burdick American Indians Into Psychology Program established under section 105(b) and the Quentin N. Burdick American Indians Into Nursing Program established under section 115.

`(c) REGULATIONS- The Secretary, pursuant to this Act, shall develop regulations to govern grants pursuant to this section.

`(d) REQUIREMENTS- Applicants for grants provided under this section shall agree to provide a program which--

`(1) provides outreach and recruitment for health professions to Indian communities, including elementary and secondary schools and community colleges located on reservations, which will be served by the program;

`(2) incorporates a program advisory board comprised of representatives from the Indian Tribes and Indian communities which will be served by the program;

`(3) provides summer preparatory programs for Indian students who need enrichment in the subjects of math and science in order to pursue training in the health professions;

`(4) provides tutoring, counseling, and support to students who are enrolled in a health career program of study at the respective college or university; and

`(5) to the maximum extent feasible, employs qualified Indians in the program.

`SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY COLLEGES.

`(a) GRANTS TO ESTABLISH PROGRAMS-

`(1) IN GENERAL- The Secretary, acting through the Service, shall award grants to accredited and accessible community colleges for the purpose of assisting such community colleges in the establishment of programs which provide education in a health profession leading to a degree or diploma in a health profession for individuals who desire to practice such profession on or near a reservation or in an Indian Health Program.

`(2) AMOUNT OF GRANTS- The amount of any grant awarded to a community college under paragraph (1) for the first year in which such a grant is provided to the community college shall not exceed $100,000.

`(b) GRANTS FOR MAINTENANCE AND RECRUITING-

`(1) IN GENERAL- The Secretary, acting through the Service, shall award grants to accredited and accessible community colleges that have established a program described in subsection (a)(1) for the purpose of maintaining the program and recruiting students for the program.

`(2) REQUIREMENTS- Grants may only be made under this section to a community college which--

`(A) is accredited;

`(B) has a relationship with a hospital facility, Service facility, or hospital that could provide training of nurses or health professionals;

`(C) has entered into an agreement with an accredited college or university medical school, the terms of which--

`(i) provide a program that enhances the transition and recruitment of students into advanced baccalaureate or graduate programs which train health professionals; and

`(ii) stipulate certifications necessary to approve internship and field placement opportunities at Indian Health Programs;

`(D) has a qualified staff which has the appropriate certifications;

`(E) is capable of obtaining State or regional accreditation of the program described in subsection (a)(1); and

`(F) agrees to provide for Indian preference for applicants for programs under this section.

`(c) TECHNICAL ASSISTANCE- The Secretary shall encourage community colleges described in subsection (b)(2) to establish and maintain programs described in subsection (a)(1) by--

`(1) entering into agreements with such colleges for the provision of qualified personnel of the Service to teach courses of study in such programs; and

`(2) providing technical assistance and support to such colleges.

`(d) ADVANCED TRAINING-

`(1) REQUIRED- Any program receiving assistance under this section that is conducted with respect to a health profession shall also offer courses of study which provide advanced training for any health professional who--

`(A) has already received a degree or diploma in such health profession; and

`(B) provides clinical services on or near a reservation or for an Indian Health Program.

`(2) MAY BE OFFERED AT ALTERNATE SITE- Such courses of study may be offered in conjunction with the college or university with which the community college has entered into the agreement required under subsection (b)(2)(C).

`(e) FUNDING PRIORITY- Where the requirements of subsection (b) are met, funding priority shall be provided to tribal colleges and universities in Service Areas where they exist.

`SEC. 119. RETENTION BONUS.

`(a) BONUS AUTHORIZED- The Secretary may pay a retention bonus to any health professional employed by, or assigned to, and serving in, an Indian Health Program or Urban Indian Organization either as a civilian employee or as a commissioned officer in the Regular or Reserve Corps of the Public Health Service who--

`(1) is assigned to, and serving in, a position for which recruitment or retention of personnel is difficult;

`(2) the Secretary determines is needed by Indian Health Programs and Urban Indian Organizations;

`(3) has--

`(A) completed 3 years of employment with an Indian Health Program or Urban Indian Organization; or

`(B) completed any service obligations incurred as a requirement of--

`(i) any Federal scholarship program; or

`(ii) any Federal education loan repayment program; and

`(4) enters into an agreement with an Indian Health Program or Urban Indian Organization for continued employment for a period of not less than 1 year.

`(b) RATES- The Secretary may establish rates for the retention bonus which shall provide for a higher annual rate for multiyear agreements than for single year agreements referred to in subsection (a)(4), but in no event shall the annual rate be more than $25,000 per annum.

`(d) OTHER RETENTION BONUS- The Secretary may pay a retention bonus to any health professional employed by a Tribal Health Program if such health professional is serving in a position which the Secretary determines is--

`(1) a position for which recruitment or retention is difficult; and

`(2) necessary for providing health care services to Indians.

`SEC. 120. NURSING RESIDENCY PROGRAM.

`(a) ESTABLISHMENT OF PROGRAM- The Secretary, acting through the Service, shall establish a program to enable Indians who are licensed practical nurses, licensed vocational nurses, and registered nurses who are working in an Indian Health Program or Urban Indian Organization, and have done so for a period of not less than 1 year, to pursue advanced training. Such program shall include a combination of education and work study in an Indian Health Program or Urban Indian Organization leading to an associate or bachelor's degree (in the case of a licensed practical nurse or licensed vocational nurse), a bachelor's degree (in the case of a registered nurse), or advanced degrees or certification in nursing and public health.

`SEC. 121. COMMUNITY HEALTH AIDE PROGRAM FOR ALASKA.

`(a) General Purposes of Program- Under the authority of the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'), the Secretary, acting through the Service, shall develop and operate a Community Health Aide Program in Alaska under which the Service--

`(1) provides for the training of Alaska Natives as health aides or community health practitioners;

`(2) uses such aides or practitioners in the provision of health care, health promotion, and disease prevention services to Alaska Natives living in villages in rural Alaska; and

`(3) provides for the establishment of teleconferencing capacity in health clinics located in or near such villages for use by community health aides or community health practitioners.

`(b) Specific Program Requirements- The Secretary, acting through the Community Health Aide Program of the Service, shall--

`(1) using trainers accredited by the Program, provide a high standard of training to community health aides and community health practitioners to ensure that such aides and practitioners provide quality health care, health promotion, and disease prevention services to the villages served by the Program;

`(2) in order to provide such training, develop a curriculum that--

`(A) combines education in the theory of health care with supervised practical experience in the provision of health care;

`(B) provides instruction and practical experience in the provision of acute care, emergency care, health promotion, disease prevention, and the efficient and effective management of clinic pharmacies, supplies, equipment, and facilities; and

`(C) promotes the achievement of the health status objectives specified in section 3(2);

`(3) establish and maintain a Community Health Aide Certification Board to certify as community health aides or community health practitioners individuals who have successfully completed the training described in paragraph (1) or can demonstrate equivalent experience;

`(4) develop and maintain a system which identifies the needs of community health aides and community health practitioners for continuing education in the provision of health care, including the areas described in paragraph (2)(B), and develop programs that meet the needs for such continuing education;

`(5) develop and maintain a system that provides close supervision of community health aides and community health practitioners;

`(6) develop a system under which the work of community health aides and community health practitioners is reviewed and evaluated to assure the provision of quality health care, health promotion, and disease prevention services; and

`(7) ensure that pupal therapy (not including pulpotomies of deciduary teeth) or extraction of adult teeth can be performed by a dental health aide therapist only after consultation with a licensed dentist who determines that the procedure is a medical emergency that cannot be resolved with palliative treatment, and further that dental health aide therapists are strictly prohibited from performing all other oral or jaw surgeries, provided that uncomplicated extractions shall not be considered oral surgery under this section.

`(c) Program Review-

`(1) NEUTRAL PANEL-

`(A) ESTABLISHMENT- The Secretary, acting through the Service, shall establish a neutral panel to carry out the study under paragraph (2).

`(B) MEMBERSHIP- Members of the neutral panel shall be appointed by the Secretary from among clinicians, economists, community practitioners, oral epidemiologists, and Alaska Natives.

`(2) STUDY-

`(A) IN GENERAL- The neutral panel established under paragraph (1) shall conduct a study of the dental health aide therapist services provided by the Community Health Aide Program under this section to ensure that the quality of care provided through those services is adequate and appropriate.

`(B) PARAMETERS OF STUDY- The Secretary, in consultation with interested parties, including professional dental organizations, shall develop the parameters of the study.

`(C) INCLUSIONS- The study shall include a determination by the neutral panel with respect to--

`(i) the ability of the dental health aide therapist services under this section to address the dental care needs of Alaska Natives;

`(ii) the quality of care provided through those services, including any training, improvement, or additional oversight required to improve the quality of care; and

`(iii) whether safer and less costly alternatives to the dental health aide therapist services exist.

`(D) CONSULTATION- In carrying out the study under this paragraph, the neutral panel shall consult with Alaska Tribal Organizations with respect to the adequacy and accuracy of the study.

`(3) REPORT- The neutral panel shall submit to the Secretary, the Committee on Indian Affairs of the Senate, and the Committee on Resources of the House of Representatives a report describing the results of the study under paragraph (2), including a description of--

`(A) any determination of the neutral panel under paragraph (2)(C); and

`(B) any comments received from an Alaska Tribal Organization under paragraph (2)(D).

`(d) Nationalization of Program-

`(1) IN GENERAL- Except as provided in paragraph (2), the Secretary, acting through the Service, may establish a national Community Health Aide Program in accordance with the program under this section, as the Secretary determines to be appropriate.

`(2) EXCEPTION- The national Community Health Aide Program under paragraph (1) shall not include dental health aide therapist services.

`(3) REQUIREMENT- In establishing a national program under paragraph (1), the Secretary shall not reduce the amount of funds provided for the Community Health Aide Program described in subsections (a) and (b).

`SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION.

`The Secretary, acting through the Service, shall, by contract or otherwise, provide training for Indians in the administration and planning of Tribal Health Programs.

`SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE DEMONSTRATION PROGRAMS.

`(a) DEMONSTRATION PROGRAMS AUTHORIZED- The Secretary, acting through the Service, may fund demonstration programs for Tribal Health Programs to address the chronic shortages of health professionals.

`(b) PURPOSES OF PROGRAMS- The purposes of demonstration programs funded under subsection (a) shall be--

`(1) to provide direct clinical and practical experience at a Service Unit to health profession students and residents from medical schools;

`(2) to improve the quality of health care for Indians by assuring access to qualified health care professionals; and

`(3) to provide academic and scholarly opportunities for health professionals serving Indians by identifying all academic and scholarly resources of the region.

`(c) ADVISORY BOARD- The demonstration programs established pursuant to subsection (a) shall incorporate a program advisory board composed of representatives from the Indian Tribes and Indian communities in the area which will be served by the program.

`SEC. 124. NATIONAL HEALTH SERVICE CORPS.

`(a) NO REDUCTION IN SERVICES- The Secretary shall not--

`(1) remove a member of the National Health Service Corps from an Indian Health Program or Urban Indian Organization; or

`(2) withdraw funding used to support such member;

unless the Secretary, acting through the Service, Indian Tribes, or Tribal Organizations, has ensured that the Indians receiving services from such member will experience no reduction in services.

`(b) EXEMPTION FROM LIMITATIONS- National Health Service Corps scholars qualifying for the Commissioned Corps in the United States Public Health Service shall be exempt from the full-time equivalent limitations of the National Health Service Corps and the Service when serving as a commissioned corps officer in a Tribal Health Program or an Urban Indian Organization.

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

`(a) GRANTS AND CONTRACTS- The Secretary, acting through the Service, may enter into contracts with, or make grants to, accredited tribal colleges and universities and eligible accredited and accessible community colleges to establish demonstration programs to develop educational curricula for substance abuse counseling.

`(b) USE OF FUNDS- Funds provided under this section shall be used only for developing and providing educational curriculum for substance abuse counseling (including paying salaries for instructors). Such curricula may be provided through satellite campus programs.

`(c) TIME PERIOD OF ASSISTANCE; RENEWAL- A contract entered into or a grant provided under this section shall be for a period of 1 year. Such contract or grant may be renewed for an additional 1-year period upon the approval of the Secretary.

`(d) CRITERIA FOR REVIEW AND APPROVAL OF APPLICATIONS- Not later than 180 days after the date of the enactment of the Indian Health Care Improvement Act Amendments of 2006, the Secretary, after consultation with Indian Tribes and administrators of tribal colleges and universities and eligible accredited and accessible community colleges, shall develop and issue criteria for the review and approval of applications for funding (including applications for renewals of funding) under this section. Such criteria shall ensure that demonstration programs established under this section promote the development of the capacity of such entities to educate substance abuse counselors.

`(e) ASSISTANCE- The Secretary shall provide such technical and other assistance as may be necessary to enable grant recipients to comply with the provisions of this section.

`(f) REPORT- Each fiscal year, the Secretary shall submit to the President, for inclusion in the report which is required to be submitted under section 801 for that fiscal year, a report on the findings and conclusions derived from the demonstration programs conducted under this section during that fiscal year.

`(g) DEFINITION- For the purposes of this section, the term `educational curriculum' means 1 or more of the following:

`(1) Classroom education.

`(2) Clinical work experience.

`(3) Continuing education workshops.

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

`(a) STUDY; LIST- The Secretary, acting through the Service, and the Secretary of the Interior, in consultation with Indian Tribes and Tribal Organizations, shall conduct a study and compile a list of the types of staff positions specified in subsection (b) whose qualifications include, or should include, training in the identification, prevention, education, referral, or treatment of mental illness, or dysfunctional and self destructive behavior.

`(b) POSITIONS- The positions referred to in subsection (a) are--

`(1) staff positions within the Bureau of Indian Affairs, including existing positions, in the fields of--

`(A) elementary and secondary education;

`(B) social services and family and child welfare;

`(C) law enforcement and judicial services; and

`(D) alcohol and substance abuse;

`(2) staff positions within the Service; and

`(3) staff positions similar to those identified in paragraphs (1) and (2) established and maintained by Indian Tribes, Tribal Organizations, (without regard to the funding source) and Urban Indian Organizations.

`(c) TRAINING CRITERIA-

`(1) IN GENERAL- The appropriate Secretary shall provide training criteria appropriate to each type of position identified in subsection (b)(1) and (b)(2) and ensure that appropriate training has been, or shall be provided to any individual in any such position. With respect to any such individual in a position identified pursuant to subsection (b)(3), the respective Secretaries shall provide appropriate training to, or provide funds to, an Indian Tribe, Tribal Organization, or Urban Indian Organization for training of appropriate individuals. In the case of positions funded under a contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.), the appropriate Secretary shall ensure that such training costs are included in the contract or compact, as the Secretary determines necessary.

`(2) POSITION SPECIFIC TRAINING CRITERIA- Position specific training criteria shall be culturally relevant to Indians and Indian Tribes and shall ensure that appropriate information regarding traditional Indian health care and treatment practices is provided.

`(d) COMMUNITY EDUCATION ON MENTAL ILLNESS- The Service shall develop and implement, on request of an Indian Tribe, Tribal Organization, or Urban Indian Organization, or assist the Indian Tribe, Tribal Organization, or Urban Indian Organization to develop and implement, a program of community education on mental illness. In carrying out this subsection, the Service shall, upon request of an Indian Tribe, Tribal Organization, or Urban Indian Organization, provide technical assistance to the Indian Tribe, Tribal Organization, or Urban Indian Organization to obtain and develop community educational materials on the identification, prevention, referral, and treatment of mental illness and dysfunctional and self-destructive behavior.

`(e) PLAN- Not later than 90 days after the date of the enactment of the Indian Health Care Improvement Act Amendments of 2006, the Secretary shall develop a plan under which the Service will increase the health care staff providing behavioral health services by at least 500 positions within 5 years after the date of the enactment of this section, with at least 200 of such positions devoted to child, adolescent, and family services. The plan developed under this subsection shall be implemented under the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act').

`TITLE II--HEALTH SERVICES

`SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND.

`(a) USE OF FUNDS- The Secretary, acting through the Service, is authorized to expend funds, directly or under the authority of the Indian Self-Determination and Education Assistance Act, (25 U.S.C. 450 et seq.), which are appropriated under the authority of this section, for the purposes of--

`(1) eliminating the deficiencies in health status and health resources of all Indian Tribes;

`(2) eliminating backlogs in the provision of health care services to Indians;

`(3) meeting the health needs of Indians in an efficient and equitable manner, including the use of telehealth and telemedicine when appropriate;

`(4) eliminating inequities in funding for both direct care and contract health service programs; and

`(5) augmenting the ability of the Service to meet the following health service responsibilities with respect to those Indian Tribes with the highest levels of health status deficiencies and resource deficiencies:

`(A) Clinical care, including, inpatient care, outpatient care (including audiology, clinical eye, and vision care), primary care, secondary and tertiary care, and long-term care.

`(B) Preventive health, including mammography and other cancer screening in accordance with section 207.

`(C) Dental care.

`(D) Mental health, including community mental health services, inpatient mental health services, dormitory mental health services, therapeutic and residential treatment centers, and training of traditional Indian practitioners.

`(E) Emergency medical services.

`(F) Treatment and control of, and rehabilitative care related to, alcoholism and drug abuse (including fetal alcohol syndrome) among Indians.

`(G) Injury prevention programs.

`(H) Home health care.

`(I) Community health representatives.

`(J) Maintenance and repair.

`(b) NO OFFSET OR LIMITATION- Any funds appropriated under the authority of this section shall not be used to offset or limit any other appropriations made to the Service under this Act or the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'), or any other provision of law.

`(c) ALLOCATION; USE-

`(1) IN GENERAL- Funds appropriated under the authority of this section shall be allocated to Service Units, Indian Tribes, or Tribal Organizations. The funds allocated to each Indian Tribe, Tribal Organization, or Service Unit under this paragraph shall be used by the Indian Tribe, Tribal Organization, or Service Unit under this paragraph to improve the health status and reduce the resource deficiency of each Indian Tribe served by such Service Unit, Indian Tribe, or Tribal Organization.

`(2) APPORTIONMENT OF ALLOCATED FUNDS- The apportionment of funds allocated to a Service Unit, Indian Tribe, or Tribal Organization under paragraph (1) among the health service responsibilities described in subsection (a)(5) shall be determined by the Service in consultation with, and with the active participation of, the affected Indian Tribes and Tribal Organizations.

`(d) PROVISIONS RELATING TO HEALTH STATUS AND RESOURCE DEFICIENCIES- For the purposes of this section, the following definitions apply:

`(1) DEFINITION- The term `health status and resource deficiency' means the extent to which--

`(A) the health status objectives set forth in section 3(2) are not being achieved; and

`(B) the Indian Tribe or Tribal Organization does not have available to it the health resources it needs, taking into account the actual cost of providing health care services given local geographic, climatic, rural, or other circumstances.

`(2) AVAILABLE RESOURCES- The health resources available to an Indian Tribe or Tribal Organization include health resources provided by the Service as well as health resources used by the Indian Tribe or Tribal Organization, including services and financing systems provided by any Federal programs, private insurance, and programs of State or local governments.

`(3) PROCESS FOR REVIEW OF DETERMINATIONS- The Secretary shall establish procedures which allow any Indian Tribe or Tribal Organization to petition the Secretary for a review of any determination of the extent of the health status and resource deficiency of such Indian Tribe or Tribal Organization.

`(e) ELIGIBILITY FOR FUNDS- Tribal Health Programs shall be eligible for funds appropriated under the authority of this section on an equal basis with programs that are administered directly by the Service.

`(f) REPORT- By no later than the date that is 3 years after the date of the enactment of the Indian Health Care Improvement Act Amendments of 2006, the Secretary shall submit to Congress the current health status and resource deficiency report of the Service for each Service Unit, including newly recognized or acknowledged Indian Tribes. Such report shall set out--

`(1) the methodology then in use by the Service for determining Tribal health status and resource deficiencies, as well as the most recent application of that methodology;

`(2) the extent of the health status and resource deficiency of each Indian Tribe served by the Service or a Tribal Health Program;

`(3) the amount of funds necessary to eliminate the health status and resource deficiencies of all Indian Tribes served by the Service or a Tribal Health Program; and

`(4) an estimate of--

`(A) the amount of health service funds appropriated under the authority of this Act, or any other Act, including the amount of any funds transferred to the Service for the preceding fiscal year which is allocated to each Service Unit, Indian Tribe, or Tribal Organization;

`(B) the number of Indians eligible for health services in each Service Unit or Indian Tribe or Tribal Organization; and

`(C) the number of Indians using the Service resources made available to each Service Unit, Indian Tribe or Tribal Organization, and, to the extent available, information on the waiting lists and number of Indians turned away for services due to lack of resources.

`(g) INCLUSION IN BASE BUDGET- Funds appropriated under this section for any fiscal year shall be included in the base budget of the Service for the purpose of determining appropriations under this section in subsequent fiscal years.

`(h) CLARIFICATION- Nothing in this section is intended to diminish the primary responsibility of the Service to eliminate existing backlogs in unmet health care needs, nor are the provisions of this section intended to discourage the Service from undertaking additional efforts to achieve equity among Indian Tribes and Tribal Organizations.

`(i) FUNDING DESIGNATION- Any funds appropriated under the authority of this section shall be designated as the `Indian Health Care Improvement Fund'.

`SEC. 202. CATASTROPHIC HEALTH EMERGENCY FUND.

`(a) ESTABLISHMENT- There is hereby established an Indian Catastrophic Health Emergency Fund (hereafter in this section referred to as the `CHEF') consisting of--

`(1) the amounts deposited under subsection (f); and

`(2) the amounts appropriated to CHEF under this section.

`(b) ADMINISTRATION- CHEF shall be administered by the Secretary, acting through the central office of the Service, solely for the purpose of meeting the extraordinary medical costs associated with the treatment of victims of disasters or catastrophic illnesses who are within the responsibility of the Service.

`(c) CONDITIONS ON USE OF FUND- No part of CHEF or its administration shall be subject to contract or grant under any law, including the Indian Self-Determination and Education Assistance Act, (25 U.S.C. 450 et seq.), nor shall CHEF funds be allocated, apportioned, or delegated on an Area Office, Service Unit, or other similar basis.

`(d) REGULATIONS- The Secretary shall, through the negotiated rulemaking process under title VIII, promulgate regulations consistent with the provisions of this section to--

`(1) establish a definition of disasters and catastrophic illnesses for which the cost of the treatment provided under contract would qualify for payment from CHEF;

`(2) provide that a Service Unit shall not be eligible for reimbursement for the cost of treatment from CHEF until its cost of treating any victim of such catastrophic illness or disaster has reached a certain threshold cost which the Secretary shall establish at--

`(A) the 2000 level of $19,000; and

`(B) for any subsequent year, not less than the threshold cost of the previous year increased by the percentage increase in the medical care expenditure category of the consumer price index for all urban consumers (United States city average) for the 12-month period ending with December of the previous year;

`(3) establish a procedure for the reimbursement of the portion of the costs that exceeds such threshold cost incurred by--

`(A) Service Units; or

`(B) whenever otherwise authorized by the Service, non-Service facilities or providers;

`(4) establish a procedure for payment from CHEF in cases in which the exigencies of the medical circumstances warrant treatment prior to the authorization of such treatment by the Service; and

`(5) establish a procedure that will ensure that no payment shall be made from CHEF to any provider of treatment to the extent that such provider is eligible to receive payment for the treatment from any other Federal, State, local, or private source of reimbursement for which the patient is eligible.

`(e) NO OFFSET OR LIMITATION- Amounts appropriated to CHEF under this section shall not be used to offset or limit appropriations made to the Service under the authority of the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'), or any other law.

`(f) DEPOSIT OF REIMBURSEMENT FUNDS- There shall be deposited into CHEF all reimbursements to which the Service is entitled from any Federal, State, local, or private source (including third party insurance) by reason of treatment rendered to any victim of a disaster or catastrophic illness the cost of which was paid from CHEF.

`SEC. 203. HEALTH PROMOTION AND DISEASE PREVENTION SERVICES.

`(a) FINDINGS- Congress finds that health promotion and disease prevention activities--

`(1) improve the health and well-being of Indians; and

`(2) reduce the expenses for health care of Indians.

`(b) PROVISION OF SERVICES- The Secretary, acting through the Service and Tribal Health Programs, shall provide health promotion and disease prevention services to Indians to achieve the health status objectives set forth in section 3(2).

`(c) EVALUATION- The Secretary, after obtaining input from the affected Tribal Health Programs, shall submit to the President for inclusion in each report which is required to be submitted to Congress under section 801 an evaluation of--

`(1) the health promotion and disease prevention needs of Indians;

`(2) the health promotion and disease prevention activities which would best meet such needs;

`(3) the internal capacity of the Service and Tribal Health Programs to meet such needs; and

`(4) the resources which would be required to enable the Service and Tribal Health Programs to undertake the health promotion and disease prevention activities necessary to meet such needs.

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

`(a) DETERMINATIONS REGARDING DIABETES- The Secretary, acting through the Service, and in consultation with Indian Tribes and Tribal Organizations, shall determine--

`(1) by an Indian Tribe, Tribal Organization, and by Service Unit, the incidence of, and the types of complications resulting from, diabetes among Indians; and

`(2) based on the determinations made pursuant to paragraph (1), the measures (including patient education and effective ongoing monitoring of disease indicators) each Service Unit should take to reduce the incidence of, and prevent, treat, and control the complications resulting from, diabetes among Indian Tribes within that Service Unit.

`(b) DIABETES SCREENING- To the extent medically indicated and with informed consent, the Secretary shall screen each Indian who receives services from the Service for diabetes and for conditions which indicate a high risk that the individual will become diabetic and, in consultation with Indian Tribes, Urban Indian Organizations, and appropriate health care providers, establish a cost-effective approach to ensure ongoing monitoring of disease indicators. Such screening and monitoring may be conducted by a Tribal Health Program and may be conducted through appropriate Internet-based health care management programs.

`(c) FUNDING FOR DIABETES- The Secretary shall continue to maintain each model diabetes project in existence on the date of the enactment of the Indian Health Care Improvement Amendments Act of 2006, any such other diabetes programs operated by the Service or Tribal Health Programs, and any additional diabetes projects, such as the Medical Vanguard program provided for in title IV of Public Law 108-87, as implemented to serve Indian Tribes. Tribal Health Programs shall receive recurring funding for the diabetes projects that they operate pursuant to this section, both at the date of enactment of the Indian Health Care Improvement Act Amendments of 2006 and for projects which are added and funded thereafter.

`(d) FUNDING FOR DIALYSIS PROGRAMS- The Secretary is authorized to provide funding through the Service, Indian Tribes, and Tribal Organizations to establish dialysis programs, including funding to purchase dialysis equipment and provide necessary staffing.

`(e) OTHER DUTIES OF THE SECRETARY-

`(1) IN GENERAL- The Secretary shall, to the extent funding is available--

`(A) in each Area Office, consult with Indian Tribes and Tribal Organizations regarding programs for the prevention, treatment, and control of diabetes;

`(B) establish in each Area office a registry of patients with diabetes to track the incidence of diabetes and the complications from diabetes in that area; and

`(C) ensure that data collected in each Area Office regarding diabetes and related complications among Indians are disseminated to all other Area Offices, subject to applicable patient privacy laws.

`(2) DIABETES CONTROL OFFICERS-

`(A) IN GENERAL- The Secretary may establish and maintain in each Area Office a position of diabetes control officer to coordinate and manage any activity of that Area Office relating to the prevention, treatment, or control of diabetes to assist the Secretary in carrying out a program under this section or section 330C of the Public Health Service Act (42 U.S.C. 254c-3).

`(B) CERTAIN ACTIVITIES- Any activity carried out by a diabetes control officer under subparagraph (A) that is the subject of a contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.), and any funds made available to carry out such an activity, shall not be divisible for purposes of that Act.

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

`(a) LONG-TERM CARE- Notwithstanding any other provision of law, the Secretary, acting through the Service, is authorized to provide directly, or enter into contracts or compacts under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) with Indian Tribes or Tribal Organizations for, the delivery of long-term care and similar services to Indians. Such agreements shall provide for the sharing of staff or other services between the Service or a Tribal Health Program and a long-term care or other similar facility owned and operated (directly or through a contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) by such Indian Tribe or Tribal Organization.

`(b) CONTENTS OF AGREEMENTS- An agreement or other arrangement entered into pursuant to subsection (a)--

`(1) may, at the request of the Indian Tribe or Tribal Organization, delegate to such Indian Tribe or Tribal Organization such powers of supervision and control over Service employees as the Secretary deems necessary to carry out the purposes of this section;

`(2) shall provide that expenses (including salaries) relating to services that are shared between the Service and the Tribal Health Program be allocated proportionately between the Service and the Indian Tribe or Tribal Organization; and

`(3) may authorize such Indian Tribe or Tribal Organization to construct, renovate, or expand a long-term care or other similar facility (including the construction of a facility attached to a Service facility).

`(c) MINIMUM REQUIREMENT- Any nursing facility provided for under this section shall meet the requirements for nursing facilities under section 1919 of the Social Security Act.

`(d) OTHER ASSISTANCE- The Secretary shall provide such technical and other assistance as may be necessary to enable applicants to comply with the provisions of this section.

`(e) USE OF EXISTING OR UNDERUSED FACILITIES- The Secretary shall encourage the use of existing facilities that are underused or allow the use of swing beds for long-term or similar care.

`SEC. 206. HEALTH SERVICES RESEARCH.

`The Secretary, acting through the Service, shall make funding available for research to further the performance of the health service responsibilities of Indian Health Programs. The Secretary shall also, to the maximum extent practicable, coordinate departmental research resources and activities to address relevant Indian Health Program research needs. Tribal Health Programs shall be given an equal opportunity to compete for, and receive, research funds under this section. This funding may be used for both clinical and nonclinical research.

`SEC. 207. MAMMOGRAPHY AND OTHER CANCER SCREENING.

`The Secretary, acting through the Service or Tribal Health Programs, shall provide for screening as follows:

`(1) Screening mammography (as defined in section 1861(jj) of the Social Security Act) for Indian women at a frequency appropriate to such women under national standards, such as those of the National Cancer Institute for the National Institutes for Health, and under such terms and conditions as are consistent with standards established by the Secretary to ensure the safety and accuracy of screening mammography under part B of title XVIII of such Act.

`(2) Other cancer screening meeting national standards, such as those of the National Cancer Institute.

`SEC. 208. PATIENT TRAVEL COSTS.

`The Secretary, acting through the Service and Tribal Health Programs, shall provide funds for the following patient travel costs, including appropriate and necessary qualified escorts, associated with receiving health care services provided (either through direct or contract care or through a contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 eq seq.) under this Act--

`(1) emergency air transportation and non-emergency air transportation where ground transportation is infeasible;

`(2) transportation by private vehicle (where no other means of transportation is available), specially equipped vehicle, and ambulance; and

`(3) transportation by such other means as may be available and required when air or motor vehicle transportation is not available.

`SEC. 209. EPIDEMIOLOGY CENTERS.

`(a) ADDITIONAL CENTERS- In addition to those epidemiology centers already established at the time of enactment of this Act, and without reducing the funding levels for such centers, not later than 180 days after the date of the enactment of the Indian Health Care Improvement Act Amendments of 2006, the Secretary, acting through the Service, shall establish an epidemiology center in each Service Area which does not yet have one to carry out the functions described in subsection (b). Any new centers so established may be operated by Tribal Health Programs, but such funding shall not be divisible.

`(b) FUNCTIONS OF CENTERS- In consultation with and at the request of Indian Tribes, Tribal Organizations, and Urban Indian Organizations, each Service Area epidemiology center established under this subsection shall, with respect to such Service Area--

`(1) collect data relating to, and monitor progress made toward meeting, each of the health status objectives of the Service, the Indian Tribes, Tribal Organizations, and Urban Indian Organizations in the Service Area;

`(2) evaluate existing delivery systems, data systems, and other systems that impact the improvement of Indian health;

`(3) assist Indian Tribes, Tribal Organizations, and Urban Indian Organizations in identifying their highest priority health status objectives and the services needed to achieve such objectives, based on epidemiological data;

`(4) make recommendations for the targeting of services needed by the populations served;

`(5) make recommendations to improve health care delivery systems for Indians and Urban Indians;

`(6) provide requested technical assistance to Indian Tribes, Tribal Organizations, and Urban Indian Organizations in the development of local health service priorities and incidence and prevalence rates of disease and other illness in the community; and

`(7) provide disease surveillance and assist Indian Tribes, Tribal Organizations, and Urban Indian Organizations to promote public health.

`(c) TECHNICAL ASSISTANCE- The Director of the Centers for Disease Control and Prevention shall provide technical assistance to the centers in carrying out the requirements of this subsection.

`(d) FUNDING FOR STUDIES- The Secretary may make funding available to Indian Tribes, Tribal Organizations, and Urban Indian Organizations to conduct epidemiological studies of Indian communities.

`SEC. 210. COMPREHENSIVE SCHOOL HEALTH EDUCATION PROGRAMS.

`(a) FUNDING FOR DEVELOPMENT OF PROGRAMS- In addition to carrying out any other program for health promotion or disease prevention, the Secretary, acting through the service, is authorized to award grants to Indian Tribes, Tribal Organizations, and Urban Indian Organizations to develop comprehensive school health education programs for children from pre-school through grade 12 in schools for the benefit of Indian and Urban Indian children.

`(b) USE OF FUNDS- A grant awarded under this section may be used for purposes which may include, but are not limited to, the following:

`(1) Developing and implementing health education curricula both for regular school programs and afterschool programs.

`(2) Training teachers in comprehensive school health education curricula.

`(3) Integrating school-based, community-based, and other public and private health promotion efforts.

`(4) Encouraging healthy, tobacco-free school environments.

`(5) Coordinating school-based health programs with existing services and programs available in the community.

`(6) Developing school programs on nutrition education, personal health, oral health, and fitness.

`(7) Developing behavioral health wellness programs.

`(8) Developing chronic disease prevention programs.

`(9) Developing substance abuse prevention programs.

`(10) Developing injury prevention and safety education programs.

`(11) Developing activities for the prevention and control of communicable diseases.

`(12) Developing community and environmental health education programs.

`(13) Violence prevention.

`(14) Such other health issues as are appropriate.

`(c) TECHNICAL ASSISTANCE- Upon request, the Secretary, acting through the Service, shall provide technical assistance to Indian Tribes, Tribal Organizations, and Urban Indian Organizations in the development of comprehensive health education plans and the dissemination of comprehensive health education materials and information on existing health programs and resources.

`(d) CRITERIA FOR REVIEW AND APPROVAL OF APPLICATIONS- The Secretary, acting through the Service, and in consultation with Indian Tribes, Tribal Organizations, and Urban Indian Organizations, shall establish criteria for the review and approval of applications for grants awarded under this section.

`(e) DEVELOPMENT OF PROGRAM FOR BIA FUNDED SCHOOLS-

`(1) IN GENERAL- The Secretary of the Interior, (acting through the Bureau of Indian Affairs) in cooperation with the Secretary (acting through the Service), and affected Indian Tribes and Tribal Organizations, shall develop a comprehensive school health education program for children from preschool through grade 12 in schools for which support is provided by the Bureau of Indian Affairs.

`(2) REQUIREMENTS FOR PROGRAMS- Such programs shall include--

`(A) school programs on nutrition education, personal health, oral health, and fitness;

`(B) behavioral health wellness programs;

`(C) chronic disease prevention programs;

`(D) substance abuse prevention programs;

`(E) injury prevention and safety education programs; and

`(F) activities for the prevention and control of communicable diseases.

`(3) DUTIES OF THE SECRETARY- The Secretary of the Interior shall--

`(A) provide training to teachers in comprehensive school health education curricula;

`(B) ensure the integration and coordination of school-based programs with existing services and health programs available in the community; and

`(C) encourage healthy, tobacco-free school environments.

`SEC. 211. INDIAN YOUTH PROGRAM.

`(a) PROGRAM AUTHORIZED- The Secretary, acting through the Service, is authorized to establish and administer a program to provide grants to Indian Tribes, Tribal Organizations, and Urban Indian Organizations for innovative mental and physical disease prevention and health promotion and treatment programs for Indian and Urban Indian preadolescent and adolescent youths.

`(b) USE OF FUNDS-

`(1) ALLOWABLE USES- Funds made available under this section may be used to--

`(A) develop prevention and treatment programs for Indian youth which promote mental and physical health and incorporate cultural values, community and family involvement, and traditional healers; and

`(B) develop and provide community training and education.

`(2) PROHIBITED USE- Funds made available under this section may not be used to provide services described in section 707(c).

`(c) DUTIES OF THE SECRETARY- The Secretary shall--

`(1) disseminate to Indian Tribes, Tribal Organizations, and Urban Indian Organizations information regarding models for the delivery of comprehensive health care services to Indian and Urban Indian adolescents;

`(2) encourage the implementation of such models; and

`(3) at the request of an Indian Tribe, Tribal Organization, or Urban Indian Organization, provide technical assistance in the implementation of such models.

`(d) CRITERIA FOR REVIEW AND APPROVAL OF APPLICATIONS- The Secretary, in consultation with Indian Tribes, Tribal Organizations, and Urban Indian Organizations, shall establish criteria for the review and approval of applications or proposals under this section.

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

`(a) FUNDING AUTHORIZED- The Secretary, acting through the Service, and after consultation with Indian Tribes, Tribal Organizations, Urban Indian Organizations, and the Centers for Disease Control and Prevention, may make funding available to Indian Tribes, Tribal Organizations, and Urban Indian Organizations for the following:

`(1) Projects for the prevention, control, and elimination of communicable and infectious diseases, including tuberculosis, hepatitis, HIV, respiratory syncytial virus, hanta virus, sexually transmitted diseases, and H. Pylori.

`(2) Public information and education programs for the prevention, control, and elimination of communicable and infectious diseases.

`(3) Education, training, and clinical skills improvement activities in the prevention, control, and elimination of communicable and infectious diseases for health professionals, including allied health professionals.

`(4) Demonstration projects for the screening, treatment, and prevention of hepatitis C virus (HCV).

`(b) APPLICATION REQUIRED- The Secretary may provide funding under subsection (a) only if an application or proposal for funding is submitted to the Secretary.

`(c) COORDINATION WITH HEALTH AGENCIES- Indian Tribes, Tribal Organizations, and Urban Indian Organizations receiving funding under this section are encouraged to coordinate their activities with the Centers for Disease Control and Prevention and State and local health agencies.

`(d) TECHNICAL ASSISTANCE; REPORT- In carrying out this section, the Secretary--

`(1) may, at the request of an Indian Tribe, Tribal Organization, or Urban Indian Organization, provide technical assistance; and

`(2) shall prepare and submit a report to Congress biennially on the use of funds under this section and on the progress made toward the prevention, control, and elimination of communicable and infectious diseases among Indians and Urban Indians.

`SEC. 213. AUTHORITY FOR PROVISION OF OTHER SERVICES.

`(a) FUNDING AUTHORIZED- The Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, may provide funding under this Act to meet the objectives set forth in section 3 through health care-related services and programs not otherwise described in this Act, including--

`(1) hospice care;

`(2) assisted living;

`(3) long-term health care;

`(4) home- and community-based services, in accordance with subsection (d); and

`(5) public health functions.

`(b) SERVICES TO OTHERWISE INELIGIBLE PERSONS- Subject to section 807, at the discretion of the Service, Indian Tribes, or Tribal Organizations, services provided for hospice care, home- and community-based care, assisted living, and long-term care may be provided (subject to reimbursement) to persons otherwise ineligible for the health care benefits of the Service. Any funds received under this subsection shall not be used to offset or limit the funding allocated to the Service or an Indian Tribe or Tribal Organization.

`(c) TERMS AND CONDITIONS- Any service provided under this section shall be consistent with accepted and appropriate standards relating to the service, including any licensing term or condition under this Act.

`(d) DEFINITIONS- For the purposes of this section, the following definitions shall apply:

`(1)(A) The term `home-and community-based services' means 1 or more of the following:

`(i) Homemaker/home health aide services.

`(ii) Personal care services.

`(iii) Chore services.

`(iv) Nursing care services provided outside of a nursing facility by, or under the supervision of, a registered nurse.

`(v) Respite care.

`(vi) Training for family members.

`(vii) Adult day care.

`(viii) Such other home- and community-based services as the Secretary, an Indian Tribe, or a Tribal Organization may approve.

`(B) The term `home- and community-based services' does not include a service provided by an immediate relative who is legally responsible for providing the service.

`(2) The term `hospice care' means the items and services specified in subparagraphs (A) through (H) of section 1861(dd)(1) of the Social Security Act (42 U.S.C. 1395x(dd)(1)), and such other services which an Indian Tribe or Tribal Organization determines are necessary and appropriate to provide in furtherance of this care.

`(3) The term `public health functions' means the provision of public health-related programs, functions, and services, including assessment, assurance, and policy development which Indian Tribes and Tribal Organizations are authorized and encouraged, in those circumstances where it meets their needs, to do by forming collaborative relationships with all levels of local, State, and Federal Government.

`SEC. 214. INDIAN WOMEN'S HEALTH CARE.

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

`SEC. 215. ENVIRONMENTAL AND NUCLEAR HEALTH HAZARDS.

`(a) STUDIES AND MONITORING- The Secretary and the Service shall conduct, in conjunction with other appropriate Federal agencies and in consultation with concerned Indian Tribes and Tribal Organizations, studies and ongoing monitoring programs to determine trends in the health hazards to Indian miners and to Indians on or near reservations and Indian communities as a result of environmental hazards which may result in chronic or life threatening health problems, such as nuclear resource development, petroleum contamination, and contamination of water source and of the food chain. Such studies shall include--

`(1) an evaluation of the nature and extent of health problems caused by environmental hazards currently exhibited among Indians and the causes of such health problems;

`(2) an analysis of the potential effect of ongoing and future environmental resource development on or near reservations and Indian communities, including the cumulative effect over time on health;

`(3) an evaluation of the types and nature of activities, practices, and conditions causing or affecting such health problems, including uranium mining and milling, uranium mine tailing deposits, nuclear power plant operation and construction, and nuclear waste disposal; oil and gas production or transportation on or near reservations or Indian communities; and other development that could affect the health of Indians and their water supply and food chain;

`(4) a summary of any findings and recommendations provided in Federal and State studies, reports, investigations, and inspections during the 5 years prior to the date of the enactment of the Indian Health Care Improvement Act Amendments of 2006 that directly or indirectly relate to the activities, practices, and conditions affecting the health or safety of such Indians; and

`(5) the efforts that have been made by Federal and State agencies and resource and economic development companies to effectively carry out an education program for such Indians regarding the health and safety hazards of such development.

`(b) HEALTH CARE PLANS- Upon completion of such studies, the Secretary and the Service shall take into account the results of such studies and, in consultation with Indian Tribes and Tribal Organizations, develop health care plans to address the health problems studied under subsection (a). The plans shall include--

`(1) methods for diagnosing and treating Indians currently exhibiting such health problems;

`(2) preventive care and testing for Indians who may be exposed to such health hazards, including the monitoring of the health of individuals who have or may have been exposed to excessive amounts of radiation or affected by other activities that have had or could have a serious impact upon the health of such individuals; and

`(3) a program of education for Indians who, by reason of their work or geographic proximity to such nuclear or other development activities, may experience health problems.

`(c) SUBMISSION OF REPORT AND PLAN TO CONGRESS- The Secretary and the Service shall submit to Congress the study prepared under subsection (a) no later than 18 months after the date of the enactment of the Indian Health Care Improvement Act Amendments of 2006. The health care plan prepared under subsection (b) shall be submitted in a report no later than 1 year after the study prepared under subsection (a) is submitted to Congress. Such report shall include recommended activities for the implementation of the plan, as well as an evaluation of any activities previously undertaken by the Service to address such health problems.

`(d) INTERGOVERNMENTAL TASK FORCE-

`(1) ESTABLISHMENT; MEMBERS- There is established an Intergovernmental Task Force to be composed of the following individuals (or their designees):

`(A) The Secretary of Energy.

`(B) The Administrator of the Environmental Protection Agency.

`(C) The Director of the Bureau of Mines.

`(D) The Assistant Secretary for Occupational Safety and Health.

`(E) The Secretary of the Interior.

`(F) The Secretary of Health and Human Services.

`(G) The Assistant Secretary of Indian Health.

`(2) DUTIES- The Task Force shall--

`(A) identify existing and potential operations related to nuclear resource development or other environmental hazards that affect or may affect the health of Indians on or near a reservation or in an Indian community; and

`(B) enter into activities to correct existing health hazards and ensure that current and future health problems resulting from nuclear resource or other development activities are minimized or reduced.

`(3) CHAIRMAN; MEETINGS- The Secretary of Health and Human Services shall be the Chairman of the Task Force. The Task Force shall meet at least twice each year.

`(e) HEALTH SERVICES TO CERTAIN EMPLOYEES- In the case of any Indian who--

`(1) as a result of employment in or near a uranium mine or mill or near any other environmental hazard, suffers from a work-related illness or condition;

`(2) is eligible to receive diagnosis and treatment services from an Indian Health Program; and

`(3) by reason of such Indian's employment, is entitled to medical care at the expense of such mine or mill operator or entity responsible for the environmental hazard, the Indian Health Program shall, at the request of such Indian, render appropriate medical care to such Indian for such illness or condition and may be reimbursed for any medical care so rendered to which such Indian is entitled at the expense of such operator or entity from such operator or entity. Nothing in this subsection shall affect the rights of such Indian to recover damages other than such amounts paid to the Indian Health Program from the employer for providing medical care for such illness or condition.

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

`(a) IN GENERAL- For fiscal years beginning with the fiscal year ending September 30, 1983, and ending with the fiscal year ending September 30, 2015, the State of Arizona shall be designated as a contract health service delivery area by the Service for the purpose of providing contract health care services to members of federally recognized Indian Tribes of Arizona.

`(b) MAINTENANCE OF SERVICES- The Service shall not curtail any health care services provided to Indians residing on reservations in the State of Arizona if such curtailment is due to the provision of contract services in such State pursuant to the designation of such State as a contract health service delivery area pursuant to subsection (a).

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

`(a) IN GENERAL- For fiscal years beginning with the fiscal year ending September 30, 2003, and ending with the fiscal year ending September 30, 2015, the State of North Dakota shall be designated as a contract health service delivery area by the Service for the purpose of providing contract health care services to members of federally recognized Indian Tribes of North Dakota.

`(b) LIMITATION- The Service shall not curtail any health care services provided to Indians residing on reservations in the State of North Dakota if such curtailment is due to the provision of contract services in such State pursuant to the designation of such State as a contract health service delivery area pursuant to subsection (a).

`SEC. 216B. SOUTH DAKOTA AS A CONTRACT HEALTH SERVICE DELIVERY AREA.

`(a) IN GENERAL- For fiscal years beginning with the fiscal year ending September 30, 2003, and ending with the fiscal year ending on September 30, 2015, the State of South Dakota shall be designated as a contract health service delivery area by the Service for the purpose of providing contract health care services to members of federally recognized Indian Tribes of South Dakota.

`(b) LIMITATION- The Service shall not curtail any health care services provided to Indians residing on reservations in the State of South Dakota if such curtailment is due to the provision of contract services in such State pursuant to the designation of such State as a contract health service delivery area pursuant to subsection (a).

`SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES PROGRAM.

`(a) FUNDING AUTHORIZED- The Secretary is authorized to fund a program using the California Rural Indian Health Board (hereafter in this section referred to as the `CRIHB') as a contract care intermediary to improve the accessibility of health services to California Indians.

`(b) REIMBURSEMENT CONTRACT- The Secretary shall enter into an agreement with the CRIHB to reimburse the CRIHB for costs (including reasonable administrative costs) incurred pursuant to this section, in providing medical treatment under contract to California Indians described in section 806(a) throughout the California contract health services delivery area described in section 218 with respect to high cost contract care cases.

`(c) ADMINISTRATIVE EXPENSES- Not more than 5 percent of the amounts provided to the CRIHB under this section for any fiscal year may be for reimbursement for administrative expenses incurred by the CRIHB during such fiscal year.

`(d) LIMITATION ON PAYMENT- No payment may be made for treatment provided hereunder to the extent payment may be made for such treatment under the Indian Catastrophic Health Emergency Fund described in section 202 or from amounts appropriated or otherwise made available to the California contract health service delivery area for a fiscal year.

`(e) ADVISORY BOARD- There is hereby established an advisory board which shall advise the CRIHB in carrying out this section. The advisory board shall be composed of representatives, selected by the CRIHB, from not less than 8 Tribal Health Programs serving California Indians covered under this section at least one half of whom are not affiliated with the CRIHB.

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

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

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

`(a) AUTHORIZATION FOR SERVICES- The Secretary, acting through the Service, is directed to provide contract health services to members of the Turtle Mountain Band of Chippewa Indians that reside in the Trenton Service Area of Divide, McKenzie, and Williams counties in the State of North Dakota and the adjoining counties of Richland, Roosevelt, and Sheridan in the State of Montana.

`(b) NO EXPANSION OF ELIGIBILITY- Nothing in this section may be construed as expanding the eligibility of members of the Turtle Mountain Band of Chippewa Indians for health services provided by the Service beyond the scope of eligibility for such health services that applied on May 1, 1986.

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

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

`SEC. 221. LICENSING.

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

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

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

`SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS.

`(a) DEADLINE FOR RESPONSE- The Service shall respond to a notification of a claim by a provider of a contract care service with either an individual purchase order or a denial of the claim within 5 working days after the receipt of such notification.

`(b) EFFECT OF UNTIMELY RESPONSE- If the Service fails to respond to a notification of a claim in accordance with subsection (a), the Service shall accept as valid the claim submitted by the provider of a contract care service.

`(c) DEADLINE FOR PAYMENT OF VALID CLAIM- The Service shall pay a valid contract care service claim within 30 days after the completion of the claim.

`SEC. 224. LIABILITY FOR PAYMENT.

`(a) NO PATIENT LIABILITY- A patient who receives contract health care services that are authorized by the Service shall not be liable for the payment of any charges or costs associated with the provision of such services.

`(b) NOTIFICATION- The Secretary shall notify a contract care provider and any patient who receives contract health care services authorized by the Service that such patient is not liable for the payment of any charges or costs associated with the provision of such services not later than 5 business days after receipt of a notification of a claim by a provider of contract care services.

`(c) NO RECOURSE- Following receipt of the notice provided under subsection (b), or, if a claim has been deemed accepted under section 223(b), the provider shall have no further recourse against the patient who received the services.

`SEC. 225. AUTHORIZATION OF APPROPRIATIONS.

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

`TITLE III--FACILITIES

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

`(a) PREREQUISITES FOR EXPENDITURE OF FUNDS- Prior to the expenditure of, or the making of any binding commitment to expend, any funds appropriated for the planning, design, construction, or renovation of facilities pursuant to the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'), the Secretary, acting through the Service, shall--

`(1) consult with any Indian Tribe that would be significantly affected by such expenditure for the purpose of determining and, whenever practicable, honoring tribal preferences concerning size, location, type, and other characteristics of any facility on which such expenditure is to be made; and

`(2) ensure, whenever practicable and applicable, that such facility meets the construction standards of any accrediting body recognized by the Secretary for the purposes of the medicare, medicaid, and SCHIP programs under titles XVIII, XIX, and XXI of the Social Security Act by not later than 1 year after the date on which the construction or renovation of such facility is completed.

`(b) CLOSURES-

`(1) EVALUATION REQUIRED- Notwithstanding any other provision of law, no facility operated by the Service may be closed if the Secretary has not submitted to Congress at least 1 year prior to the date of the proposed closure an evaluation of the impact of the proposed closure which specifies, in addition to other considerations--

`(A) the accessibility of alternative health care resources for the population served by such facility;

`(B) the cost-effectiveness of such closure;

`(C) the quality of health care to be provided to the population served by such facility after such closure;

`(D) the availability of contract health care funds to maintain existing levels of service;

`(E) the views of the Indian Tribes served by such facility concerning such closure;

`(F) the level of use of such facility by all eligible Indians; and

`(G) the distance between such facility and the nearest operating Service hospital.

`(2) EXCEPTION FOR CERTAIN TEMPORARY CLOSURES- Paragraph (1) shall not apply to any temporary closure of a facility or any portion of a facility if such closure is necessary for medical, environmental, or construction safety reasons.

`(c) HEALTH CARE FACILITY PRIORITY SYSTEM-

`(1) IN GENERAL-

`(A) ESTABLISHMENT- The Secretary, acting through the Service, shall establish a health care facility priority system, which shall--

`(i) be developed with Indian Tribes and Tribal Organizations through negotiated rulemaking under section 802;

`(ii) give Indian Tribes' needs the highest priority; and

`(iii) at a minimum, include the lists required in paragraph (2)(B) and the methodology required in paragraph (2)(E).

`(B) PRIORITY OF CERTAIN PROJECTS PROTECTED- The priority of any project established under the construction priority system in effect on the date of the Indian Health Care Improvement Act Amendments of 2006 shall not be affected by any change in the construction priority system taking place thereafter if the project was identified as 1 of the 10 top-priority inpatient projects, 1 of the 10 top-priority outpatient projects, 1 of the 10 top-priority staff quarters developments, or 1 of the 10 top-priority Youth Regional Treatment Centers in the fiscal year 2005 Indian Health Service budget justification, or if the project had completed both Phase I and Phase II of the construction priority system in effect on the date of the enactment of such Act.

`(2) REPORT; CONTENTS- The Secretary shall submit to the President, for inclusion in each report required to be transmitted to Congress under section 801, a report which sets forth the following:

`(A) A description of the health care facility priority system of the Service, established under paragraph (1).

`(B) Health care facilities lists, including--

`(i) the 10 top-priority inpatient health care facilities;

`(ii) the 10 top-priority outpatient health care facilities;

`(iii) the 10 top-priority specialized health care facilities (such as long-term care and alcohol and drug abuse treatment);

`(iv) the 10 top-priority staff quarters developments associated with health care facilities; and

`(v) the 10 top-priority patient hostels associated with health care facilities.

`(C) The justification for such order of priority.

`(D) The projected cost of such projects.

`(E) The methodology adopted by the Service in establishing priorities under its health care facility priority system.

`(3) REQUIREMENTS FOR PREPARATION OF REPORTS- In preparing each report required under paragraph (2) (other than the initial report), the Secretary shall annually--

`(A) consult with and obtain information on all health care facilities needs from Indian Tribes, Tribal Organizations, and Urban Indian Organizations; and

`(B) review the total unmet needs of all Indian Tribes, Tribal Organizations, and Urban Indian Organizations for health care facilities (including hostels and staff quarters), including needs for renovation and expansion of existing facilities.

`(4) CRITERIA FOR EVALUATING NEEDS- For purposes of this subsection, the Secretary shall, in evaluating the needs of facilities operated under any contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) use the same criteria that the Secretary uses in evaluating the needs of facilities operated directly by the Service.

`(5) NEEDS OF FACILITIES UNDER ISDEAA AGREEMENTS- The Secretary shall ensure that the planning, design, construction, and renovation needs of Service and non-Service facilities operated under funding agreements in accordance with the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) are fully and equitably integrated into the health care facility priority system.

`(d) REVIEW OF NEED FOR FACILITIES-

`(1) In the year 2006, the Government Accountability Office shall prepare and finalize a report which sets forth the needs of the Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, for the facilities listed under subsection (c)(2)(B), including the needs for renovation and expansion of existing facilities. The Government Accountability Office shall submit the report to the appropriate authorizing and appropriations committees of Congress and to the Secretary.

`(2) Beginning in the year 2006, the Secretary shall update the report required under paragraph (1) every 5 years.

`(3) In preparing an updated report under paragraph (2), the Secretary shall consult with Indian Tribes, Tribal Organizations, and Urban Indian Organizations. The Secretary shall submit the report under paragraph (2) for inclusion in the report required to be transmitted to Congress under section 801.

`(4) For purposes of this subsection, the reports shall, regarding the needs of facilities operated under any contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.), be based on the same criteria that the Secretary uses in evaluating the needs of facilities operated directly by the Service.

`(5) The planning, design, construction, and renovation needs of facilities operated under Funding Agreement shall be fully and equitably integrated into the development of the health facility priority system.

`(6) Beginning in the year 2007 and each fiscal year thereafter, the Secretary shall provide an opportunity for nomination of planning, design, and construction projects by the Service, Indian Tribes, and Tribal Organizations for consideration under the health care facility priority system.

`(e) FUNDING CONDITION- All funds appropriated under the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'), for the planning, design, construction, or renovation of health facilities for the benefit of 1 or more Indian Tribes shall be subject to the provisions of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.).

`(f) DEVELOPMENT OF INNOVATIVE APPROACHES- The Secretary shall consult and cooperate with Indian Tribes, Tribal Organizations, and Urban Indian Organizations in developing innovative approaches to address all or part of the total unmet need for construction of health facilities, including those provided for in other sections of this title and other approaches.

`SEC. 302. SANITATION FACILITIES.

`(a) FINDINGS- Congress finds the following:

`(1) The provision of sanitation facilities is primarily a health consideration and function.

`(2) Indian people suffer an inordinately high incidence of disease, injury, and illness directly attributable to the absence or inadequacy of sanitation facilities.

`(3) The long-term cost to the United States of treating and curing such disease, injury, and illness is substantially greater than the short-term cost of providing sanitation facilities and other preventive health measures.

`(4) Many Indian homes and Indian communities still lack sanitation facilities.

`(5) It is in the interest of the United States, and it is the policy of the United States, that all Indian communities and Indian homes, new and existing, be provided with sanitation facilities.

`(b) FACILITIES AND SERVICES- In furtherance of the findings made in subsection (a), Congress reaffirms the primary responsibility and authority of the Service to provide the necessary sanitation facilities and services as provided in section 7 of the Act of August 5, 1954 (42 U.S.C. 2006a). Under such authority, the Secretary, acting through the Service, is authorized to provide the following:

`(1) Financial and technical assistance to Indian Tribes, Tribal Organizations, and Indian communities in the establishment, training, and equipping of utility organizations to operate and maintain sanitation facilities, including the provision of existing plans, standard details, and specifications available in the Department, to be used at the option of the Indian Tribe, Tribal Organization, or Indian community.

`(2) Ongoing technical assistance and training to Indian Tribes, Tribal Organizations, and Indian communities in the management of utility organizations which operate and maintain sanitation facilities.

`(3) Priority funding for operation and maintenance assistance for, and emergency repairs to, sanitation facilities operated by an Indian Tribe, Tribal Organization or Indian community when necessary to avoid an imminent health threat or to protect the investment in sanitation facilities and the investment in the health benefits gained through the provision of sanitation facilities.

`(c) FUNDING- Notwithstanding any other provision of law--

`(1) the Secretary of Housing and Urban Development is authorized to transfer funds appropriated under the Native American Housing Assistance and Self-Determination Act of 1996 to the Secretary of Health and Human Services;

`(2) the Secretary of Health and Human Services is authorized to accept and use such funds for the purpose of providing sanitation facilities and services for Indians under section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a);

`(3) unless specifically authorized when funds are appropriated, the Secretary shall not use funds appropriated under section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a), to provide sanitation facilities to new homes constructed using funds provided by the Department of Housing and Urban Development;

`(4) the Secretary of Health and Human Services is authorized to accept from any source, including Federal and State agencies, funds for the purpose of providing sanitation facilities and services and place these funds into contracts or compacts under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.);

`(5) except as otherwise prohibited by this section, the Secretary may use funds appropriated under the authority of section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a) to fund up to 100 percent of the amount of an Indian Tribe's loan obtained under any Federal program for new projects to construct eligible sanitation facilities to serve Indian homes;

`(6) except as otherwise prohibited by this section, the Secretary may use funds appropriated under the authority of section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a) to meet matching or cost participation requirements under other Federal and non-Federal programs for new projects to construct eligible sanitation facilities;

`(7) all Federal agencies are authorized to transfer to the Secretary funds identified, granted, loaned, or appropriated whereby the Department's applicable policies, rules, and regulations shall apply in the implementation of such projects;

`(8) the Secretary shall enter into interagency agreements with Federal and State agencies for the purpose of providing financial assistance for sanitation facilities and services under this Act; and

`(9) the Secretary shall, by regulation developed through rulemaking under section 802, establish standards applicable to the planning, design, and construction of sanitation facilities funded under this Act.

`(d) CERTAIN CAPABILITIES NOT PREREQUISITE- The financial and technical capability of an Indian Tribe, Tribal Organization, or Indian community to safely operate, manage, and maintain a sanitation facility shall not be a prerequisite to the provision or construction of sanitation facilities by the Secretary.

`(e) FINANCIAL ASSISTANCE- The Secretary is authorized to provide financial assistance to Indian Tribes, Tribal Organizations, and Indian communities for operation, management, and maintenance of their sanitation facilities.

`(f) OPERATION, MANAGEMENT, AND MAINTENANCE OF FACILITIES- The Indian Tribe, Tribal Organization, or Indian community has the primary responsibility to establish, collect, and use reasonable user fees, or otherwise set aside funding, for the purpose of operating, managing, and maintaining sanitation facilities. If a sanitation facility serving a community that is operated by an Indian Tribe, Tribal Organization, or Indian community is threatened with imminent failure and such operator lacks capacity to maintain the integrity or the health benefits of the sanitation facility, then the Secretary is authorized to assist the Indian Tribe, Tribal Organization, or Indian community in the resolution of the problem on a short-term basis through cooperation with the emergency coordinator or by providing operation, management, and maintenance service.

`(g) ISDEAA PROGRAM FUNDED ON EQUAL BASIS- Tribal Health Programs shall be eligible (on an equal basis with programs that are administered directly by the Service) for--

`(1) any funds appropriated pursuant to this section; and

`(2) any funds appropriated for the purpose of providing sanitation facilities.

`(h) REPORT-

`(1) REQUIRED; CONTENTS- The Secretary, in consultation with the Secretary of Housing and Urban Development, Indian Tribes, Tribal Organizations, and tribally designated housing entities (as defined in section 4 of the Native American Housing Assistance and Self-Determination Act of 1996 (25 U.S.C. 4103)) shall submit to the President, for inclusion in each report required to be transmitted to Congress under section 801, a report which sets forth--

`(A) the current Indian sanitation facility priority system of the Service;

`(B) the methodology for determining sanitation deficiencies and needs;

`(C) the level of initial and final sanitation deficiency for each type of sanitation facility for each project of each Indian Tribe or Indian community;

`(D) the amount and most effective use of funds, derived from whatever source, necessary to accommodate the sanitation facilities needs of new homes assisted with funds under the Native American Housing Assistance and Self-Determination Act, and to reduce the identified sanitation deficiency levels of all Indian Tribes and Indian communities to level I sanitation deficiency as defined in paragraph (4)(A); and

`(E) a 10-year plan to provide sanitation facilities to serve existing Indian homes and Indian communities and new and renovated Indian homes.

`(2) CRITERIA- The criteria on which the deficiencies and needs will be evaluated shall be developed through negotiated rulemaking pursuant to section 802.

`(3) UNIFORM METHODOLOGY- The methodology used by the Secretary in determining, preparing cost estimates for, and reporting sanitation deficiencies for purposes of paragraph (1) shall be applied uniformly to all Indian Tribes and Indian communities.

`(4) SANITATION DEFICIENCY LEVELS- For purposes of this subsection, the sanitation deficiency levels for an individual, Indian Tribe or Indian community sanitation facility to serve Indian homes are determined as follows:

`(A) A level I deficiency exists if a sanitation facility serving an individual, Indian Tribe, or Indian community--

`(i) complies with all applicable water supply, pollution control, and solid waste disposal laws; and

`(ii) deficiencies relate to routine replacement, repair, or maintenance needs.

`(B) A level II deficiency exists if a sanitation facility serving an individual, Indian Tribe, or Indian community substantially or recently complied with all applicable water supply, pollution control, and solid waste laws and any deficiencies relate to--

`(i) small or minor capital improvements needed to bring the facility back into compliance;

`(ii) capital improvements that are necessary to enlarge or improve the facilities in order to meet the current needs for domestic sanitation facilities; or

`(iii) the lack of equipment or training by an Indian Tribe, Tribal Organization, or an Indian community to properly operate and maintain the sanitation facilities.

`(C) A level III deficiency exists if a sanitation facility serving an individual, Indian Tribe or Indian community meets one or more of the following conditions--

`(i) water or sewer service in the home is provided by a haul system with holding tanks and interior plumbing;

`(ii) major significant interruptions to water supply or sewage disposal occur frequently, requiring major capital improvements to correct the deficiencies; or

`(iii) there is no access to or no approved or permitted solid waste facility available.

`(D) A level IV deficiency exists--

`(i) if a sanitation facility for an individual home, an Indian Tribe, or an Indian community exists but--

`(I) lacks--

`(aa) a safe water supply system; or

`(bb) a waste disposal system;

`(II) contains no piped water or sewer facilities; or

`(III) has become inoperable due to a major component failure; or

`(ii) if only a washeteria or central facility exists in the community.

`(E) A level V deficiency exists in the absence of a sanitation facility, where individual homes do not have access to safe drinking water or adequate wastewater (including sewage) disposal.

`(i) DEFINITIONS- For purposes of this section, the following terms apply:

`(1) INDIAN COMMUNITY- The term `Indian community' means a geographic area, a significant proportion of whose inhabitants are Indians and which is served by or capable of being served by a facility described in this section.

`(2) SANITATION FACILITIES- The terms `sanitation facility' and `sanitation facilities' mean safe and adequate water supply systems, sanitary sewage disposal systems, and sanitary solid waste systems (and all related equipment and support infrastructure).

`SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS.

`(a) BUY INDIAN ACT- The Secretary, acting through the Service, may use the negotiating authority of section 23 of the Act of June 25, 1910 (25 U.S.C. 47, commonly known as the `Buy Indian Act'), to give preference to any Indian or any enterprise, partnership, corporation, or other type of business organization owned and controlled by an Indian or Indians including former or currently federally recognized Indian Tribes in the State of New York (hereinafter referred to as an `Indian firm') in the construction and renovation of Service facilities pursuant to section 301 and in the construction of sanitation facilities pursuant to section 302. Such preference may be accorded by the Secretary unless the Secretary finds, pursuant to regulations adopted pursuant to section 802, that the project or function to be contracted for will not be satisfactory or such project or function cannot be properly completed or maintained under the proposed contract. The Secretary, in arriving at such a finding, shall consider whether the Indian or Indian firm will be deficient with respect to--

`(1) ownership and control by Indians;

`(2) equipment;

`(3) bookkeeping and accounting procedures;

`(4) substantive knowledge of the project or function to be contracted for;

`(5) adequately trained personnel; or

`(6) other necessary components of contract performance.

`(b) LABOR STANDARDS-

`(1) IN GENERAL- For the purposes of implementing the provisions of this title, contracts for the construction or renovation of health care facilities, staff quarters, and sanitation facilities, and related support infrastructure, funded in whole or in part with funds made available pursuant to this title, shall contain a provision requiring compliance with subchapter IV of chapter 31 of title 40, United States Code (commonly known as the `Davis-Bacon Act'), unless such construction or renovation--

`(A) is performed by a contractor pursuant to a contract with an Indian Tribe or Tribal Organization with funds supplied through a contract, compact or funding agreement authorized by the Indian Self-Determination and Education Assistance Act, (25 U.S.C. 450 et seq.), or other statutory authority; and

`(B) is subject to prevailing wage rates for similar construction or renovation in the locality as determined by the Indian Tribes or Tribal Organizations to be served by the construction or renovation.

`(2) EXCEPTION- This subsection shall not apply to construction or renovation carried out by an Indian Tribe or Tribal Organization with its own employees.

`SEC. 304. EXPENDITURE OF NONSERVICE FUNDS FOR RENOVATION.

`(a) IN GENERAL- Notwithstanding any other provision of law, if the requirements of subsection (c) are met, the Secretary, acting through the Service, is authorized to accept any major expansion, renovation, or modernization by any Indian Tribe or Tribal Organization of any Service facility or of any other Indian health facility operated pursuant to a contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) including--

`(1) any plans or designs for such expansion, renovation, or modernization; and

`(2) any expansion, renovation, or modernization for which funds appropriated under any Federal law were lawfully expended.

`(b) PRIORITY LIST-

`(1) IN GENERAL- The Secretary shall maintain a separate priority list to address the needs for increased operating expenses, personnel, or equipment for such facilities. The methodology for establishing priorities shall be developed through negotiated rulemaking under section 802. The list of priority facilities will be revised annually in consultation with Indian Tribes and Tribal Organizations.

`(2) REPORT- The Secretary shall submit to the President, for inclusion in each report required to be transmitted to Congress under section 801, the priority list maintained pursuant to paragraph (1).

`(c) REQUIREMENTS- The requirements of this subsection are met with respect to any expansion, renovation, or modernization if--

`(1) the Indian Tribe or Tribal Organization--

`(A) provides notice to the Secretary of its intent to expand, renovate, or modernize; and

`(B) applies to the Secretary to be placed on a separate priority list to address the needs of such new facilities for increased operating expenses, personnel, or equipment; and

`(2) the expansion, renovation, or modernization--

`(A) is approved by the appropriate area director of the Service for Federal facilities; and

`(B) is administered by the Indian Tribe or Tribal Organization in accordance with any applicable regulations prescribed by the Secretary with respect to construction or renovation of Service facilities.

`(d) ADDITIONAL REQUIREMENT FOR EXPANSION- In addition to the requirements in subsection (c), for any expansions, the Indian Tribe or Tribal Organization shall provide to the Secretary additional information developed through negotiated rulemaking under section 802, including additional staffing, equipment, and other costs associated with the expansion.

`(e) CLOSURE OR CONVERSION OF FACILITIES- If any Service facility which has been expanded, renovated, or modernized by an Indian Tribe or Tribal Organization under this section ceases to be used as a Service facility during the 20-year period beginning on the date such expansion, renovation, or modernization is completed, such Indian Tribe or Tribal Organization shall be entitled to recover from the United States an amount which bears the same ratio to the value of such facility at the time of such cessation as the value of such expansion, renovation, or modernization (less the total amount of any funds provided specifically for such facility under any Federal program that were expended for such expansion, renovation, or modernization) bore to the value of such facility at the time of the completion of such expansion, renovation, or modernization.

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

`(a) FUNDING-

`(1) IN GENERAL- The Secretary, acting through the Service, in consultation with Indian Tribes and Tribal Organizations, shall make grants to Indian Tribes and Tribal Organizations for the construction, expansion, or modernization of facilities for the provision of ambulatory care services to eligible Indians (and noneligible persons pursuant to subsections (b)(2) and (c)(1)(C)). Funding made under this section may cover up to 100 percent of the costs of such construction, expansion, or modernization. For the purposes of this section, the term `construction' includes the replacement of an existing facility.

`(2) GRANTS AGREEMENT REQUIRED- A grant under paragraph (1) may only be made available to a Tribal Health Program operating an Indian health facility (other than a facility owned or constructed by the Service, including a facility originally owned or constructed by the Service and transferred to an Indian Tribe or Tribal Organization).

`(b) USE OF GRANT-

`(1) ALLOWABLE USES- Grant awarded under this section may be used for the construction, expansion, or modernization (including the planning and design of such construction, expansion, or modernization) of an ambulatory care facility--

`(A) located apart from a hospital;

`(B) not funded under section 301 or section 307; and

`(C) which, upon completion of such construction or modernization will--

`(i) have a total capacity appropriate to its projected service population;

`(ii) provide annually no fewer than 150 patient visits by eligible Indians and other users who are eligible for services in such facility in accordance with section 807(c)(2); and

`(iii) provide ambulatory care in a Service Area (specified in the contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) with a population of no fewer than 1,500 eligible Indians and other users who are eligible for services in such facility in accordance with section 807(c)(2).

`(2) ADDITIONAL ALLOWABLE USE- The Secretary may also reserve a portion of the funding provided under this section and use those reserved funds to reduce an outstanding debt incurred by Indian Tribes or Tribal Organizations for the construction, expansion, or modernization of an ambulatory care facility that meets the requirements under paragraph (1). The provisions of this section shall apply, except that such applications for funding under this paragraph shall be considered separately from applications for funding under paragraph (1).

`(3) USE ONLY FOR CERTAIN PORTION OF COSTS- A grant provided under this section may be used only for the cost of that portion of a construction, expansion, or modernization project or debt reduction that benefits the Service population identified above in subsection (b)(1)(C) (ii) and (iii).

`(4) APPLICABILITY OF REQUIREMENTS IN THE CASE OF ISOLATED FACILITIES- The requirements of clauses (ii) and (iii) of paragraph (1)(C) shall not apply to an Indian Tribe or Tribal Organization applying for a grant under this section for a health care facility located or to be constructed on an island or when such facility is not located on a road system providing direct access to an inpatient hospital where care is available to the Service population.

`(c) GRANTS-

`(1) APPLICATION- No grant may be made available under this section unless an application or proposal for the grant has been approved by the Secretary in accordance with applicable regulations and has provided reasonable assurance by the applicant that, at all times after the construction, expansion, or modernization of a facility carried out using a grant received under this section--

`(A) adequate financial support will be available for the provision of services at such facility;

`(B) such facility will be available to eligible Indians without regard to ability to pay or source of payment; and

`(C) such facility will, as feasible without diminishing the quality or quantity of services provided to eligible Indians, serve noneligible persons on a cost basis.

`(2) PRIORITY- In awarding grants under this section, the Secretary shall give priority to Indian Tribes and Tribal Organizations that demonstrate--

`(A) a need for increased ambulatory care services; and

`(B) insufficient capacity to deliver such services.

`(3) PEER REVIEW PANELS- The Secretary may provide for the establishment of peer review panels, as necessary, to review and evaluate applications and proposals and to advise the Secretary regarding such applications using the criteria developed during consultations pursuant to subsection (a)(1).

`(d) REVERSION OF FACILITIES- If any facility (or portion thereof) with respect to which funds have been paid under this section, ceases, within 5 years after completion of the construction, expansion, or modernization carried out with such funds, to be used for the purposes of providing health care services to eligible Indians, all of the right, title, and interest in and to such facility (or portion thereof) shall transfer to the United States unless otherwise negotiated by the Service and the Indian Tribe or Tribal Organization.

`(e) FUNDING NONRECURRING- Funding provided under this section shall be nonrecurring and shall not be available for inclusion in any individual Indian Tribe's tribal share for an award under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) or for reallocation or redesign thereunder.

`SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRATION PROJECT.

`(a) HEALTH CARE DEMONSTRATION PROJECTS- The Secretary, acting through the Service, and in consultation with Indian Tribes and Tribal Organizations, is authorized to enter into construction project agreements and construction contracts under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) with Indian Tribes or Tribal Organizations for the purpose of carrying out a health care delivery demonstration project to test alternative means of delivering health care and services to Indians through facilities, including hospice, traditional Indian health, and child care facilities.

`(b) USE OF FUNDS- The Secretary, in approving projects pursuant to this section, may authorize funding for the construction and renovation of hospitals, health centers, health stations, and other facilities to deliver health care services and is authorized to--

`(1) waive any leasing prohibition;

`(2) permit carryover of funds appropriated for the provision of health care services;

`(3) permit the use of other available funds;

`(4) permit the use of funds or property donated from any source for project purposes;

`(5) provide for the reversion of donated real or personal property to the donor; and

`(6) permit the use of Service funds to match other funds, including Federal funds.

`(c) REGULATIONS- The Secretary shall develop and promulgate regulations not later than 1 year after the date of enactment of the Indian Health Care Improvement Act Amendments of 2006. If the Secretary has not promulgated regulations by that date, the Secretary shall develop and publish regulations, through rulemaking under section 802, for the review and approval of applications submitted under this section.

`(d) CRITERIA- The Secretary may approve projects that meet the following criteria:

`(1) There is a need for a new facility or program or the reorientation of an existing facility or program.

`(2) A significant number of Indians, including those with low health status, will be served by the project.

`(3) The project has the potential to deliver services in an efficient and effective manner.

`(4) The project is economically viable.

`(5) The Indian Tribe or Tribal Organization has the administrative and financial capability to administer the project.

`(6) The project is integrated with providers of related health and social services and is coordinated with, and avoids duplication of, existing services.

`(e) PEER REVIEW PANELS- The Secretary may provide for the establishment of peer review panels, as necessary, to review and evaluate applications using the criteria developed pursuant to subsection (d).

`(f) PRIORITY- The Secretary shall give priority to applications for demonstration projects in each of the following Service Units to the extent that such applications are timely filed and meet the criteria specified in subsection (d):

`(1) Cass Lake, Minnesota.

`(2) Clinton, Oklahoma.

`(3) Harlem, Montana.

`(4) Mescalero, New Mexico.

`(5) Owyhee, Nevada.

`(6) Parker, Arizona.

`(7) Schurz, Nevada.

`(8) Winnebago, Nebraska.

`(9) Ft. Yuma, California.

`(g) TECHNICAL ASSISTANCE- The Secretary shall provide such technical and other assistance as may be necessary to enable applicants to comply with the provisions of this section.

`(h) SERVICE TO INELIGIBLE PERSONS- The authority to provide services to persons otherwise ineligible for the health care benefits of the Service and the authority to extend hospital privileges in Service facilities to non-Service health practitioners as provided in section 807 may be included, subject to the terms of such section, in any demonstration project approved pursuant to this section.

`(i) EQUITABLE TREATMENT- For purposes of subsection (d)(1), the Secretary shall, in evaluating facilities operated under any contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) use the same criteria that the Secretary uses in evaluating facilities operated directly by the Service.

`(j) EQUITABLE INTEGRATION OF FACILITIES- The Secretary shall ensure that the planning, design, construction, renovation, and expansion needs of Service and non-Service facilities which are the subject of a contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) for health services are fully and equitably integrated into the implementation of the health care delivery demonstration projects under this section.

`SEC. 307. LAND TRANSFER.

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

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

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

`(a) IN GENERAL- The Secretary, in consultation with the Secretary of the Treasury, Indian Tribes, and Tribal Organizations, shall carry out a study to determine the feasibility of establishing a loan fund to provide to Indian Tribes and Tribal Organizations direct loans or guarantees for loans for the construction of health care facilities, including--

`(1) inpatient facilities;

`(2) outpatient facilities;

`(3) staff quarters;

`(4) hostels; and

`(5) specialized care facilities, such as behavioral health and elder care facilities.

`(b) DETERMINATIONS- In carrying out the study under subsection (a), the Secretary shall determine--

`(1) the maximum principal amount of a loan or loan guarantee that should be offered to a recipient from the loan fund;

`(2) the percentage of eligible costs, not to exceed 100 percent, that may be covered by a loan or loan guarantee from the loan fund (including costs relating to planning, design, financing, site land development, construction, rehabilitation, renovation, conversion, improvements, medical equipment and furnishings, and other facility-related costs and capital purchase (but excluding staffing));

`(3) the cumulative total of the principal of direct loans and loan guarantees, respectively, that may be outstanding at any 1 time;

`(4) the maximum term of a loan or loan guarantee that may be made for a facility from the loan fund;

`(5) the maximum percentage of funds from the loan fund that should be allocated for payment of costs associated with planning and applying for a loan or loan guarantee;

`(6) whether acceptance by the Secretary of an assignment of the revenue of an Indian Tribe or Tribal Organization as security for any direct loan or loan guarantee from the loan fund would be appropriate;

`(7) whether, in the planning and design of health facilities under this section, users eligible under section 807(c) may be included in any projection of patient population;

`(8) whether funds of the Service provided through loans or loan guarantees from the loan fund should be eligible for use in matching other Federal funds under other programs;

`(9) the appropriateness of, and best methods for, coordinating the loan fund with the health care priority system of the Service under section 301; and

`(10) any legislative or regulatory changes required to implement recommendations of the Secretary based on results of the study.

`(c) REPORT- Not later than September 30, 2007, the Secretary shall submit to the Committee on Indian Affairs of the Senate and the Committee on Resources and the Committee on Energy and Commerce of the House of Representatives a report that describes--

`(1) the manner of consultation made as required by subsection (a); and

`(2) the results of the study, including any recommendations of the Secretary based on results of the study.

`SEC. 310. TRIBAL LEASING.

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

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

`(a) IN GENERAL- The Secretary, acting through the Service, shall make arrangements with Indian Tribes and Tribal Organizations to establish joint venture demonstration projects under which an Indian Tribe or Tribal Organization shall expend tribal, private, or other available funds, for the acquisition or construction of a health facility for a minimum of 10 years, under a no-cost lease, in exchange for agreement by the Service to provide the equipment, supplies, and staffing for the operation and maintenance of such a health facility. An Indian Tribe or Tribal Organization may use tribal funds, private sector, or other available resources, including loan guarantees, to fulfill its commitment under a joint venture entered into under this subsection. An Indian Tribe or Tribal Organization shall be eligible under this section if, when it submits a letter of intent, it--

`(1) has begun but not completed the process of acquisition or construction of a health facility to be used in the joint venture project; or

`(2) has not begun the process of acquisition or construction of a health facility for use in the joint venture project.

`(b) REQUIREMENTS- The Secretary shall make such an arrangement with an Indian Tribe or Tribal Organization only if--

`(1) the Secretary first determines that the Indian Tribe or Tribal Organization has the administrative and financial capabilities necessary to complete the timely acquisition or construction of the relevant health facility; and

`(2) the Indian Tribe or Tribal Organization meets the need criteria which shall be developed through the negotiated rulemaking process provided for under section 802.

`(c) CONTINUED OPERATION- The Secretary shall negotiate an agreement with the Indian Tribe or Tribal Organization regarding the continued operation of the facility at the end of the initial 10 year no-cost lease period.

`(d) BREACH OF AGREEMENT- An Indian Tribe or Tribal Organization that has entered into a written agreement with the Secretary under this section, and that breaches or terminates without cause such agreement, shall be liable to the United States for the amount that has been paid to the Indian Tribe or Tribal Organization, or paid to a third party on the Indian Tribe's or Tribal Organization's behalf, under the agreement. The Secretary has the right to recover tangible property (including supplies) and equipment, less depreciation, and any funds expended for operations and maintenance under this section. The preceding sentence does not apply to any funds expended for the delivery of health care services, personnel, or staffing.

`(e) RECOVERY FOR NONUSE- An Indian Tribe or Tribal Organization that has entered into a written agreement with the Secretary under this subsection shall be entitled to recover from the United States an amount that is proportional to the value of such facility if, at any time within the 10-year term of the agreement, the Service ceases to use the facility or otherwise breaches the agreement.

`(f) DEFINITION- For the purposes of this section, the term `health facility' or `health facilities' includes quarters needed to provide housing for staff of the relevant Tribal Health Program.

`SEC. 312. LOCATION OF FACILITIES.

`(a) IN GENERAL- In all matters involving the reorganization or development of Service facilities or in the establishment of related employment projects to address unemployment conditions in economically depressed areas, the Bureau of Indian Affairs and the Service shall give priority to locating such facilities and projects on Indian lands or lands in Alaska owned by any Alaska Native village, or village or regional corporation under the Alaska Native Claims Settlement Act, or any land allotted to any Alaska Native, if requested by the Indian owner and the Indian Tribe with jurisdiction over such lands or other lands owned or leased by the Indian Tribe or Tribal Organization. Top priority shall be given to Indian land owned by 1 or more Indian Tribes.

`(b) DEFINITION- For purposes of this section, the term `Indian lands' means--

`(1) all lands within the exterior boundaries of any reservation; and

`(2) any lands title to which is held in trust by the United States for the benefit of any Indian Tribe or individual Indian or held by any Indian Tribe or individual Indian subject to restriction by the United States against alienation.

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

`(a) REPORT- The Secretary shall submit to the President, for inclusion in the report required to be transmitted to Congress under section 801, a report which identifies the backlog of maintenance and repair work required at both Service and tribal health care facilities, including new health care facilities expected to be in operation in the next fiscal year. The report shall also identify the need for renovation and expansion of existing facilities to support the growth of health care programs.

`(b) MAINTENANCE OF NEWLY CONSTRUCTED SPACE- The Secretary, acting through the Service, is authorized to expend maintenance and improvement funds to support maintenance of newly constructed space only if such space falls within the approved supportable space allocation for the Indian Tribe or Tribal Organization. Supportable space allocation shall be defined through the negotiated rulemaking process provided for under section 802.

`(c) REPLACEMENT FACILITIES- In addition to using maintenance and improvement funds for renovation, modernization, and expansion of facilities, an Indian Tribe or Tribal Organization may use maintenance and improvement funds for construction of a replacement facility if the costs of renovation of such facility would exceed a maximum renovation cost threshold. The maximum renovation cost threshold shall be determined through the negotiated rulemaking process provided for under section 802.

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

`(a) RENTAL RATES-

`(1) ESTABLISHMENT- Notwithstanding any other provision of law, a Tribal Health Program which operates a hospital or other health facility and the federally owned quarters associated therewith pursuant to a contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) shall have the authority to establish the rental rates charged to the occupants of such quarters by providing notice to the Secretary of its election to exercise such authority.

`(2) OBJECTIVES- In establishing rental rates pursuant to authority of this subsection, a Tribal Health Program shall endeavor to achieve the following objectives:

`(A) To base such rental rates on the reasonable value of the quarters to the occupants thereof.

`(B) To generate sufficient funds to prudently provide for the operation and maintenance of the quarters, and subject to the discretion of the Tribal Health Program, to supply reserve funds for capital repairs and replacement of the quarters.

`(3) EQUITABLE FUNDING- Any quarters whose rental rates are established by a Tribal Health Program pursuant to this subsection shall remain eligible for quarters improvement and repair funds to the same extent as all federally owned quarters used to house personnel in Services-supported programs.

`(4) NOTICE OF RATE CHANGE- A Tribal Health Program which exercises the authority provided under this subsection shall provide occupants with no less than 60 days notice of any change in rental rates.

`(b) DIRECT COLLECTION OF RENT-

`(1) IN GENERAL- Notwithstanding any other provision of law, and subject to paragraph (2), a Tribal Health Program shall have the authority to collect rents directly from Federal employees who occupy such quarters in accordance with the following:

`(A) The Tribal Health Program shall notify the Secretary and the subject Federal employees of its election to exercise its authority to collect rents directly from such Federal employees.

`(B) Upon receipt of a notice described in subparagraph (A), the Federal employees shall pay rents for occupancy of such quarters directly to the Tribal Health Program and the Secretary shall have no further authority to collect rents from such employees through payroll deduction or otherwise.

`(C) Such rent payments shall be retained by the Tribal Health Program and shall not be made payable to or otherwise be deposited with the United States.

`(D) Such rent payments shall be deposited into a separate account which shall be used by the Tribal Health Program for the maintenance (including capital repairs and replacement) and operation of the quarters and facilities as the Tribal Health Program shall determine.

`(2) RETROCESSION OF AUTHORITY- If a Tribal Health Program which has made an election under paragraph (1) requests retrocession of its authority to directly collect rents from Federal employees occupying federally owned quarters, such retrocession shall become effective on the earlier of--

`(A) the first day of the month that begins no less than 180 days after the Tribal Health Program notifies the Secretary of its desire to retrocede; or

`(B) such other date as may be mutually agreed by the Secretary and the Tribal Health Program.

`(c) RATES IN ALASKA- To the extent that a Tribal Health Program, pursuant to authority granted in subsection (a), establishes rental rates for federally owned quarters provided to a Federal employee in Alaska, such rents may be based on the cost of comparable private rental housing in the nearest established community with a year-round population of 1,500 or more individuals.

`SEC. 315. APPLICABILITY OF BUY AMERICAN ACT REQUIREMENT.

`(a) APPLICABILITY- The Secretary shall ensure that the requirements of the Buy American Act apply to all procurements made with funds provided pursuant to section 317. Indian Tribes and Tribal Organizations shall be exempt from these requirements.

`(b) EFFECT OF VIOLATION- If it has been finally determined by a court or Federal agency that any person intentionally affixed a label bearing a `Made in America' inscription or any inscription with the same meaning, to any product sold in or shipped to the United States that is not made in the United States, such person shall be ineligible to receive any contract or subcontract made with funds provided pursuant to section 317, pursuant to the debarment, suspension, and ineligibility procedures described in sections 9.400 through 9.409 of title 48, Code of Federal Regulations.

`(c) DEFINITIONS- For purposes of this section, the term `Buy American Act' means title III of the Act entitled `An Act making appropriations for the Treasury and Post Office Departments for the fiscal year ending June 30, 1934, and for other purposes', approved March 3, 1933 (41 U.S.C. 10a et seq.).

`SEC. 316. OTHER FUNDING FOR FACILITIES.

`(a) AUTHORITY TO ACCEPT FUNDS- The Secretary is authorized to accept from any source, including Federal and State agencies, funds that are available for the construction of health care facilities and use such funds to plan, design, and construct health care facilities for Indians and to transfer such funds to Indian Tribes or Tribal Organizations through construction project agreements or construction contracts under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.). Receipt of such funds shall have no effect on the priorities established pursuant to section 301.

`(b) INTERAGENCY AGREEMENTS- The Secretary is authorized to enter into interagency agreements with other Federal agencies or State agencies and other entities and to accept funds from such Federal or State agencies or other sources to provide for the planning, design, and construction of health care facilities to be administered by Indian Health Programs in order to carry out the purposes of this Act and the purposes for which the funds were appropriated or for which the funds were otherwise provided.

`(c) TRANSFERRED FUNDS- Any Federal agency to which funds for the construction of health care facilities are appropriated is authorized to transfer such funds to the Secretary for the construction of health care facilities to carry out the purposes of this Act as well as the purposes for which such funds are appropriated to such other Federal agency.

`(d) ESTABLISHMENT OF STANDARDS- The Secretary, through the Service, shall establish standards by regulation, developed by rulemaking under section 802, for the planning, design, and construction of health care facilities serving Indians under this Act.

`SEC. 317. AUTHORIZATION OF APPROPRIATIONS.

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

`TITLE IV--ACCESS TO HEALTH SERVICES

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

`(a) Disregard of Medicare, Medicaid, and SCHIP Payments in Determining Appropriations- Any payments received by an Indian Health Program or by an Urban Indian Organization under title XVIII, XIX, or XXI of the Social Security Act for services provided to Indians eligible for benefits under such respective titles shall not be considered in determining appropriations for the provision of health care and services to Indians.

`(b) Nonpreferential Treatment- Nothing in this Act authorizes the Secretary to provide services to an Indian with coverage under title XVIII, XIX, or XXI of the Social Security Act in preference to an Indian without such coverage.

`(c) Use of Funds-

`(1) SPECIAL FUND-

`(A) 100 PERCENT PASS-THROUGH OF PAYMENTS DUE TO FACILITIES- Notwithstanding any other provision of law, but subject to paragraph (2), payments to which a facility of the Service is entitled by reason of a provision of the Social Security Act shall be placed in a special fund to be held by the Secretary. In making payments from such fund, the Secretary shall ensure that each Service Unit of the Service receives 100 percent of the amount to which the facilities of the Service, for which such Service Unit makes collections, are entitled by reason of a provision of the Social Security Act.

`(B) USE OF FUNDS- Amounts received by a facility of the Service under subparagraph (A) shall first be used (to such extent or in such amounts as are provided in appropriation Acts) for the purpose of making any improvements in the programs of the Service operated by or through such facility which may be necessary to achieve or maintain compliance with the applicable conditions and requirements of titles XVIII and XIX of the Social Security Act. Any amounts so received that are in excess of the amount necessary to achieve or maintain such conditions and requirements shall, subject to consultation with the Indian Tribes being served by the Service Unit, be used for reducing the health resource deficiencies (as determined under section 201(d)) of such Indian Tribes.

`(2) DIRECT PAYMENT OPTION- Paragraph (1) shall not apply to a Tribal Health Program or Urban Indian Organization upon the election of such Program or Organization under subsection (d) to receive payments directly. No payment may be made out of the special fund described in such paragraph with respect to reimbursement made for services provided by such Program during the period of such election.

`(d) Direct Billing-

`(1) IN GENERAL- Subject to complying with the requirements of paragraph (2), a Tribal Health Program or Urban Indian Organization may elect to directly bill for, and receive payment for, health care items and services provided by such Program or Organization for which payment is made under title XVIII or XIX of the Social Security Act or from any other third party payor.

`(2) DIRECT REIMBURSEMENT-

`(A) USE OF FUNDS- Each Tribal Health Program or Urban Indian Organization making the election described in paragraph (1) with respect to a program under a title of the Social Security Act shall be reimbursed directly by that program for items and services furnished without regard to subsection (c)(1), but all amounts so reimbursed shall be used by the Tribal Health Program or Urban Indian Organization for the purpose of making any improvements in facilities of the Tribal Health Program or Urban Indian Organization that may be necessary to achieve or maintain compliance with the conditions and requirements applicable generally to such items and services under the program under such title and to provide additional health care services, improvements in health care facilities and Tribal Health Programs, any health care related purpose, or otherwise to achieve the objectives provided in section 3 of this Act.

`(B) AUDITS- The amounts paid to a Tribal Health Program or Urban Indian Organization making the election described in paragraph (1) with respect to a program under a title of the Social Security Act shall be subject to all auditing requirements applicable to the program under such title, as well as all auditing requirements applicable to programs administered by an Indian Health Program. Nothing in the preceding sentence shall be construed as limiting the application of auditing requirements applicable to amounts paid under title XVIII, XIX, or XXI of the Social Security Act.

`(C) IDENTIFICATION OF SOURCE OF PAYMENTS- Any Tribal Health Program or Urban Indian Organization that receives reimbursements or payments under title XVIII, XIX, or XXI of the Social Security Act, shall provide to the Service a list of each provider enrollment number (or other identifier) under which such Program or Organization receives such reimbursements or payments.

`(3) EXAMINATION AND IMPLEMENTATION OF CHANGES-

`(A) IN GENERAL- The Secretary, acting through the Service and with the assistance of the Administrator of the Centers for Medicare & Medicaid Services, shall examine on an ongoing basis and implement any administrative changes that may be necessary to facilitate direct billing and reimbursement under the program established under this subsection, including any agreements with States that may be necessary to provide for direct billing under a program under a title of the Social Security Act.

`(B) COORDINATION OF INFORMATION- The Service shall provide the Administrator of the Centers for Medicare & Medicaid Services with copies of the lists submitted to the Service under paragraph (2)(C), enrollment data regarding patients served by the Service (and by Tribal Health Programs and Urban Indian Organizations, to the extent such data is available to the Service), and such other information as the Administrator may require for purposes of administering title XVIII, XIX, or XXI of the Social Security Act.

`(4) WITHDRAWAL FROM PROGRAM- A Tribal Health Program or Urban Indian Organization that bills directly under the program established under this subsection may withdraw from participation in the same manner and under the same conditions that an Indian Tribe or Tribal Organization may retrocede a contracted program to the Secretary under the authority of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.). All cost accounting and billing authority under the program established under this subsection shall be returned to the Secretary upon the Secretary's acceptance of the withdrawal of participation in this program.

`(5) TERMINATION FOR FAILURE TO COMPLY WITH REQUIREMENTS- The Secretary may terminate the participation of a Tribal Health Program or an Urban Indian Organization in the direct billing program established under this subsection if the Secretary determines that the Program or Organization has failed to comply with the requirements of paragraph (2). The Secretary shall provide a Tribal Health Program or Urban Indian Organization with notice of a determination that the Program or Organization has failed to comply with any such requirement and a reasonable opportunity to correct such noncompliance prior to terminating the Program's or Organization's participation in the direct billing program established under this subsection.

`(e) Related Provisions Under the Social Security Act- For provisions related to subsections (c) and (d), see sections 1880, 1911, and 2107(e)(1)(D) of the Social Security Act.

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

`(a) Indian Tribes and Tribal Organizations- From funds appropriated to carry out this title in accordance with section 415, the Secretary, acting through the Service, shall make grants to or enter into contracts with Indian Tribes and Tribal Organizations to assist such Tribes and Tribal Organizations in establishing and administering programs on or near reservations and trust lands to assist individual Indians--

`(1) to enroll for benefits under a program established under title XVIII, XIX, or XXI of the Social Security Act and other health benefits programs; and

`(2) with respect to such programs for which the charging of premiums and cost sharing is not prohibited under such programs, to pay premiums or cost sharing for coverage for such benefits, which may be based on financial need (as determined by the Indian Tribe or Tribes or Tribal Organizations being served based on a schedule of income levels developed or implemented by such Tribe, Tribes, or Tribal Organizations).

`(b) Conditions- The Secretary, acting through the Service, shall place conditions as deemed necessary to effect the purpose of this section in any grant or contract which the Secretary makes with any Indian Tribe or Tribal Organization pursuant to this section. Such conditions shall include requirements that the Indian Tribe or Tribal Organization successfully undertake--

`(1) to determine the population of Indians eligible for the benefits described in subsection (a);

`(2) to educate Indians with respect to the benefits available under the respective programs;

`(3) to provide transportation for such individual Indians to the appropriate offices for enrollment or applications for such benefits; and

`(4) to develop and implement methods of improving the participation of Indians in receiving benefits under such programs.

`(c) Application to Urban Indian Organizations-

`(1) IN GENERAL- The provisions of subsection (a) shall apply with respect to grants and other funding to Urban Indian Organizations with respect to populations served by such organizations in the same manner they apply to grants and contracts with Indian Tribes and Tribal Organizations with respect to programs on or near reservations.

`(2) REQUIREMENTS- The Secretary shall include in the grants or contracts made or provided under paragraph (1) requirements that are--

`(A) consistent with the requirements imposed by the Secretary under subsection (b);

`(B) appropriate to Urban Indian Organizations and Urban Indians; and

`(C) necessary to effect the purposes of this section.

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

`(e) Agreements Relating to Improving Enrollment of Indians Under Social Security Act Health Benefits Programs- For provisions relating to agreements between the Secretary, acting through the Service, and Indian Tribes, Tribal Organizations, and Urban Indian Organization for the collection, preparation, and submission of applications by Indians for assistance under the Medicaid and State children's health insurance programs established under titles XIX and XXI of the Social Security Act, and benefits under the Medicare program established under title XVIII of such Act, see subsections (a) and (b) of section 1139 of the Social Security Act.

`(f) Definition of Premiums and Cost Sharing- In this section:

`(1) PREMIUM- The term `premium' includes any enrollment fee or similar charge.

`(2) COST SHARING- The term `cost sharing' includes any deduction, deductible, copayment, coinsurance, or similar charge.

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

`(a) Right of Recovery- Except as provided in subsection (f), the United States, an Indian Tribe, or Tribal Organization shall have the right to recover from an insurance company, health maintenance organization, employee benefit plan, third-party tortfeasor, or any other responsible or liable third party (including a political subdivision or local governmental entity of a State) the reasonable expenses billed by the Secretary, an Indian Tribe, or Tribal Organization, in providing health services, through the Service, an Indian Tribe, or Tribal Organization to any individual to the same extent that such individual, or any nongovernmental provider of such services, would be eligible to receive damages, reimbursement, or indemnification for such charges or expenses if--

`(1) such services had been provided by a nongovernmental provider; and

`(2) such individual had been required to pay such charges or expenses and did pay such charges or expenses.

`(b) Limitations on Recoveries From States- Subsection (a) shall provide a right of recovery against any State, only if the injury, illness, or disability for which health services were provided is covered under--

`(1) workers' compensation laws; or

`(2) a no-fault automobile accident insurance plan or program.

`(c) Nonapplication of Other Laws- No law of any State, or of any political subdivision of a State and no provision of any contract, insurance or health maintenance organization policy, employee benefit plan, self-insurance plan, managed care plan, or other health care plan or program entered into or renewed after the date of the enactment of the Indian Health Care Amendments of 1988, shall prevent or hinder the right of recovery of the United States, an Indian Tribe, or Tribal Organization under subsection (a).

`(d) No Effect on Private Rights of Action- No action taken by the United States, an Indian Tribe, or Tribal Organization to enforce the right of recovery provided under this section shall operate to deny to the injured person the recovery for that portion of the person's damage not covered hereunder.

`(e) Enforcement-

`(1) IN GENERAL- The United States, an Indian Tribe, or Tribal Organization may enforce the right of recovery provided under subsection (a) by--

`(A) intervening or joining in any civil action or proceeding brought--

`(i) by the individual for whom health services were provided by the Secretary, an Indian Tribe, or Tribal Organization; or

`(ii) by any representative or heirs of such individual, or

`(B) instituting a civil action, including a civil action for injunctive relief and other relief and including, with respect to a political subdivision or local governmental entity of a State, such an action against an official thereof.

`(2) NOTICE- All reasonable efforts shall be made to provide notice of action instituted under paragraph (1)(B) to the individual to whom health services were provided, either before or during the pendency of such action.

`(f) Limitation- Absent specific written authorization by the governing body of an Indian Tribe for the period of such authorization (which may not be for a period of more than 1 year and which may be revoked at any time upon written notice by the governing body to the Service), the United States shall not have a right of recovery under this section if the injury, illness, or disability for which health services were provided is covered under a self-insurance plan funded by an Indian Tribe, Tribal Organization, or Urban Indian Organization. Where such authorization is provided, the Service may receive and expend such amounts for the provision of additional health services consistent with such authorization.

`(g) Costs and Attorneys' Fees- In any action brought to enforce the provisions of this section, a prevailing plaintiff shall be awarded its reasonable attorneys' fees and costs of litigation.

`(h) Nonapplication of Claims Filing Requirements- An insurance company, health maintenance organization, self-insurance plan, managed care plan, or other health care plan or program (under the Social Security Act or otherwise) may not deny a claim for benefits submitted by the Service or by an Indian Tribe or Tribal Organization based on the format in which the claim is submitted if such format complies with the format required for submission of claims under title XVIII of the Social Security Act or recognized under section 1175 of such Act.

`(i) Application to Urban Indian Organizations- The previous provisions of this section shall apply to Urban Indian Organizations with respect to populations served by such Organizations in the same manner they apply to Indian Tribes and Tribal Organizations with respect to populations served by such Indian Tribes and Tribal Organizations.

`(j) Statute of Limitations- The provisions of section 2415 of title 28, United States Code, shall apply to all actions commenced under this section, and the references therein to the United States are deemed to include Indian Tribes, Tribal Organizations, and Urban Indian Organizations.

`(k) Savings- Nothing in this section shall be construed to limit any right of recovery available to the United States, an Indian Tribe, or Tribal Organization under the provisions of any applicable, Federal, State, or Tribal law, including medical lien laws and the Federal Medical Care Recovery Act (42 U.S.C. 2651 et seq.).

`SEC. 404. CREDITING OF REIMBURSEMENTS.

`(a) Use of Amounts-

`(1) RETENTION BY PROGRAM- Except as provided in section 202(g) (relating to the Catastrophic Health Emergency Fund) and section 807 (relating to health services for ineligible persons), all reimbursements received or recovered under any of the programs described in paragraph (2), including under section 807, by reason of the provision of health services by the Service, by an Indian Tribe or Tribal Organization, or by an Urban Indian Organization, shall be credited to the Service, such Indian Tribe or Tribal Organization, or such Urban Indian Organization, respectively, and may be used as provided in section 401. In the case of such a service provided by or through a Service Unit, such amounts shall be credited to such unit and used for such purposes.

`(2) PROGRAMS COVERED- The programs referred to in paragraph (1) are the following:

`(A) Titles XVIII, XIX, and XXI of the Social Security Act.

`(B) This Act, including section 807.

`(C) Public Law 87-693.

`(D) Any other provision of law.

`(b) No Offset of Amounts- The Service may not offset or limit any amount obligated to any Service Unit or entity receiving funding from the Service because of the receipt of reimbursements under subsection (a).

`SEC. 405. PURCHASING HEALTH CARE COVERAGE.

`(a) In General- Insofar as amounts are made available under law (including a provision of the Social Security Act, the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.), or other law, other than under section 402) to Indian Tribes, Tribal Organizations, and Urban Indian Organizations for health benefits for Service beneficiaries, Indian Tribes, Tribal Organizations, and Urban Indian Organizations may use such amounts to purchase health benefits coverage for such beneficiaries in any manner, including through--

`(1) a tribally owned and operated health care plan;

`(2) a State or locally authorized or licensed health care plan;

`(3) a health insurance provider or managed care organization; or

`(4) a self-insured plan.

The purchase of such coverage by an Indian Tribe, Tribal Organization, or Urban Indian Organization may be based on the financial needs of such beneficiaries (as determined by the Indian Tribe or Tribes being served based on a schedule of income levels developed or implemented by such Indian Tribe or Tribes).

`(b) Expenses for Self-Insured Plan- In the case of a self-insured plan under subsection (a)(4), the amounts may be used for expenses of operating the plan, including administration and insurance to limit the financial risks to the entity offering the plan.

`(c) Construction- Nothing in this section shall be construed as affecting the use of any amounts not referred to in subsection (a).

`SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGENCIES.

`(a) Authority-

`(1) IN GENERAL- The Secretary may enter into (or expand) arrangements for the sharing of medical facilities and services between the Service, Indian Tribes, and Tribal Organizations and the Department of Veterans Affairs and the Department of Defense.

`(2) CONSULTATION BY SECRETARY REQUIRED- The Secretary may not finalize any arrangement between the Service and a Department described in paragraph (1) without first consulting with the Indian Tribes which will be significantly affected by the arrangement.

`(b) Limitations- The Secretary shall not take any action under this section or under subchapter IV of chapter 81 of title 38, United States Code, which would impair--

`(1) the priority access of any Indian to health care services provided through the Service and the eligibility of any Indian to receive health services through the Service;

`(2) the quality of health care services provided to any Indian through the Service;

`(3) the priority access of any veteran to health care services provided by the Department of Veterans Affairs;

`(4) the quality of health care services provided by the Department of Veterans Affairs or the Department of Defense; or

`(5) the eligibility of any Indian who is a veteran to receive health services through the Department of Veterans Affairs.

`(c) Reimbursement- The Service, Indian Tribe, or Tribal Organization shall be reimbursed by the Department of Veterans Affairs or the Department of Defense (as the case may be) where services are provided through the Service, an Indian Tribe, or a Tribal Organization to beneficiaries eligible for services from either such Department, notwithstanding any other provision of law.

`(d) Construction- Nothing in this section may be construed as creating any right of a non-Indian veteran to obtain health services from the Service.

`SEC. 407. PAYOR OF LAST RESORT.

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

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

`(a) Requirement to Satisfy Generally Applicable Participation Requirements-

`(1) IN GENERAL- A Federal health care program must accept an entity that is operated by the Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization as a provider eligible to receive payment under the program for health care services furnished to an Indian on the same basis as any other provider qualified to participate as a provider of health care services under the program if the entity meets generally applicable State or other requirements for participation as a provider of health care services under the program.

`(2) SATISFACTION OF STATE OR LOCAL LICENSURE OR RECOGNITION REQUIREMENTS- Any requirement for participation as a provider of health care services under a Federal health care program that an entity be licensed or recognized under the State or local law where the entity is located to furnish health care services shall be deemed to have been met in the case of an entity operated by the Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization if the entity meets all the applicable standards for such licensure or recognition, regardless of whether the entity obtains a license or other documentation under such State or local law. In accordance with section 221, the absence of the licensure of a health care professional employed by such an entity under the State or local law where the entity is located shall not be taken into account for purposes of determining whether the entity meets such standards, if the professional is licensed in another State.

`(b) Application of Exclusion From Participation in Federal Health Care Programs-

`(1) EXCLUDED ENTITIES- No entity operated by the Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization that has been excluded from participation in any Federal health care program or for which a license is suspended or has been revoked by the State where the entity is located shall be eligible to receive payment or reimbursement under any such program for health care services furnished to an Indian.

`(2) EXCLUDED INDIVIDUALS- No individual who has been excluded from participation in any Federal health care program or whose State license is under suspension shall be eligible to receive payment or reimbursement under any such program for health care services furnished by that individual, directly or through an entity that is otherwise eligible to receive payment for health care services, to an Indian.

`(3) FEDERAL HEALTH CARE PROGRAM DEFINED- In this subsection, the term, `Federal health care program' has the meaning given that term in section 1128B(f) of the Social Security Act (42 U.S.C. 1320a-7b(f)), except that, for purposes of this subsection, such term shall include the health insurance program under chapter 89 of title 5, United States Code.

`(c) Related Provisions- For provisions related to nondiscrimination against providers operated by the Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization, see section 1139(c) of the Social Security Act (42 U.S.C. 1320b-9(c)).

`SEC. 409. CONSULTATION.

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

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

`For provisions relating to--

`(1) outreach to families of Indian children likely to be eligible for child health assistance under the State children's health insurance program established under title XXI of the Social Security Act, see sections 2105(c)(2)(C) and 1139(a) of such Act (42 U.S.C. 1397ee(c)(2), 1320b-9); and

`(2) ensuring that child health assistance is provided under such program to targeted low-income children who are Indians and that payments are made under such program to Indian Health Programs and Urban Indian Organizations operating in the State that provide such assistance, see sections 2102(b)(3)(D) and 2105(c)(6)(B) of such Act (42 U.S.C. 1397bb(b)(3)(D), 1397ee(c)(6)(B)).

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

`For provisions relating to--

`(1) exclusion waiver authority for affected Indian Health Programs under the Social Security Act, see section 1128(k) of the Social Security Act (42 U.S.C. 1320a-7(k)); and

`(2) certain transactions involving Indian Health Programs deemed to be in safe harbors under that Act, see section 1128B(b)(4) of the Social Security Act (42 U.S.C. 1320a-7b(b)(4)).

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

`For provisions relating to--

`(1) premiums or cost sharing protections for Indians furnished items or services directly by Indian Health Programs or through referral under the contract health service under the Medicaid program established under title XIX of the Social Security Act, see sections 1916(j) and 1916A(a)(1) of the Social Security Act (42 U.S.C. 1396o(j), 1396o-1(a)(1));

`(2) rules regarding the treatment of certain property for purposes of determining eligibility under such programs, see sections 1902(e)(13) and 2107(e)(1)(B) of such Act (42 U.S.C. 1396a(e)(13), 1397gg(e)(1)(B)); and

`(3) the protection of certain property from estate recovery provisions under the Medicaid program, see section 1917(b)(3)(B) of such Act (42 U.S.C. 1396p(b)(3)(B)).

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

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

`SEC. 414. NAVAJO NATION MEDICAID AGENCY FEASIBILITY STUDY.

`(a) Study- The Secretary shall conduct a study to determine the feasibility of treating the Navajo Nation as a State for the purposes of title XIX of the Social Security Act, to provide services to Indians living within the boundaries of the Navajo Nation through an entity established having the same authority and performing the same functions as single-State medicaid agencies responsible for the administration of the State plan under title XIX of the Social Security Act.

`(b) Considerations- In conducting the study, the Secretary shall consider the feasibility of--

`(1) assigning and paying all expenditures for the provision of services and related administration funds, under title XIX of the Social Security Act, to Indians living within the boundaries of the Navajo Nation that are currently paid to or would otherwise be paid to the State of Arizona, New Mexico, or Utah;

`(2) providing assistance to the Navajo Nation in the development and implementation of such entity for the administration, eligibility, payment, and delivery of medical assistance under title XIX of the Social Security Act;

`(3) providing an appropriate level of matching funds for Federal medical assistance with respect to amounts such entity expends for medical assistance for services and related administrative costs; and

`(4) authorizing the Secretary, at the option of the Navajo Nation, to treat the Navajo Nation as a State for the purposes of title XIX of the Social Security Act (relating to the State children's health insurance program) under terms equivalent to those described in paragraphs (2) through (4).

`(c) Report- Not later then 3 years after the date of enactment of the Indian Health Act Improvement Act Amendments of 2006, the Secretary shall submit to the Committee on Indian Affairs and Committee on Finance of the Senate and the Committee on Resources and Committee on Energy and Commerce of the House of Representatives a report that includes--

`(1) the results of the study under this section;

`(2) a summary of any consultation that occurred between the Secretary and the Navajo Nation, other Indian Tribes, the States of Arizona, New Mexico, and Utah, counties which include Navajo Lands, and other interested parties, in conducting this study;

`(3) projected costs or savings associated with establishment of such entity, and any estimated impact on services provided as described in this section in relation to probable costs or savings; and

`(4) legislative actions that would be required to authorize the establishment of such entity if such entity is determined by the Secretary to be feasible.

`SEC. 415. AUTHORIZATION OF APPROPRIATIONS.

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

`TITLE V--HEALTH SERVICES FOR URBAN INDIANS

`SEC. 501. PURPOSE.

`The purpose of this title is to establish and maintain programs in Urban Centers to make health services more accessible and available to Urban Indians.

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

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

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

`(a) REQUIREMENTS FOR GRANTS AND CONTRACTS- Under authority of the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'), the Secretary, acting through the Service, shall enter into contracts with, or make grants to, Urban Indian Organizations for the provision of health care and referral services for Urban Indians. Any such contract or grant shall include requirements that the Urban Indian Organization successfully undertake to--

`(1) estimate the population of Urban Indians residing in the Urban Center or centers that the organization proposes to serve who are or could be recipients of health care or referral services;

`(2) estimate the current health status of Urban Indians residing in such Urban Center or centers;

`(3) estimate the current health care needs of Urban Indians residing in such Urban Center or centers;

`(4) provide basic health education, including health promotion and disease prevention education, to Urban Indians;

`(5) make recommendations to the Secretary and Federal, State, local, and other resource agencies on methods of improving health service programs to meet the needs of Urban Indians; and

`(6) where necessary, provide, or enter into contracts for the provision of, health care services for Urban Indians.

`(b) CRITERIA- The Secretary, acting through the Service, shall, by regulation adopted pursuant to section 520, prescribe the criteria for selecting Urban Indian Organizations to enter into contracts or receive grants under this section. Such criteria shall, among other factors, include--

`(1) the extent of unmet health care needs of Urban Indians in the Urban Center or centers involved;

`(2) the size of the Urban Indian population in the Urban Center or centers involved;

`(3) the extent, if any, to which the activities set forth in subsection (a) would duplicate any project funded under this title;

`(4) the capability of an Urban Indian Organization to perform the activities set forth in subsection (a) and to enter into a contract with the Secretary or to meet the requirements for receiving a grant under this section;

`(5) the satisfactory performance and successful completion by an Urban Indian Organization of other contracts with the Secretary under this title;

`(6) the appropriateness and likely effectiveness of conducting the activities set forth in subsection (a) in an Urban Center or centers; and

`(7) the extent of existing or likely future participation in the activities set forth in subsection (a) by appropriate health and health-related Federal, State, local, and other agencies.

`(c) ACCESS TO HEALTH PROMOTION AND DISEASE PREVENTION PROGRAMS- The Secretary, acting through the Service, shall facilitate access to or provide health promotion and disease prevention services for Urban Indians through grants made to Urban Indian Organizations administering contracts entered into or receiving grants under subsection (a).

`(d) IMMUNIZATION SERVICES-

`(1) ACCESS OR SERVICES PROVIDED- The Secretary, acting through the Service, shall facilitate access to, or provide, immunization services for Urban Indians through grants made to Urban Indian Organizations administering contracts entered into or receiving grants under this section.

`(2) DEFINITION- For purposes of this subsection, the term `immunization services' means services to provide without charge immunizations against vaccine-preventable diseases.

`(e) BEHAVIORAL HEALTH SERVICES-

`(1) ACCESS OR SERVICES PROVIDED- The Secretary, acting through the Service, shall facilitate access to, or provide, behavioral health services for Urban Indians through grants made to Urban Indian Organizations administering contracts entered into or receiving grants under subsection (a).

`(2) ASSESSMENT REQUIRED- Except as provided by paragraph (3)(A), a grant may not be made under this subsection to an Urban Indian Organization until that organization has prepared, and the Service has approved, an assessment of the following:

`(A) The behavioral health needs of the Urban Indian population concerned.

`(B) The behavioral health services and other related resources available to that population.

`(C) The barriers to obtaining those services and resources.

`(D) The needs that are unmet by such services and resources.

`(3) PURPOSES OF GRANTS- Grants may be made under this subsection for the following:

`(A) To prepare assessments required under paragraph (2).

`(B) To provide outreach, educational, and referral services to Urban Indians regarding the availability of direct behavioral health services, to educate Urban Indians about behavioral health issues and services, and effect coordination with existing behavioral health providers in order to improve services to Urban Indians.

`(C) To provide outpatient behavioral health services to Urban Indians, including the identification and assessment of illness, therapeutic treatments, case management, support groups, family treatment, and other treatment.

`(D) To develop innovative behavioral health service delivery models which incorporate Indian cultural support systems and resources.

`(f) PREVENTION OF CHILD ABUSE-

`(1) ACCESS OR SERVICES PROVIDED- The Secretary, acting through the Service, shall facilitate access to or provide services for Urban Indians through grants to Urban Indian Organizations administering contracts entered into or receiving grants under subsection (a) to prevent and treat child abuse (including sexual abuse) among Urban Indians.

`(2) EVALUATION REQUIRED- Except as provided by paragraph (3)(A), a grant may not be made under this subsection to an Urban Indian Organization until that organization has prepared, and the Service has approved, an assessment that documents the prevalence of child abuse in the Urban Indian population concerned and specifies the services and programs (which may not duplicate existing services and programs) for which the grant is requested.

`(3) PURPOSES OF GRANTS- Grants may be made under this subsection for the following:

`(A) To prepare assessments required under paragraph (2).

`(B) For the development of prevention, training, and education programs for Urban Indians, including child education, parent education, provider training on identification and intervention, education on reporting requirements, prevention campaigns, and establishing service networks of all those involved in Indian child protection.

`(C) To provide direct outpatient treatment services (including individual treatment, family treatment, group therapy, and support groups) to Urban Indians who are child victims of abuse (including sexual abuse) or adult survivors of child sexual abuse, to the families of such child victims, and to Urban Indian perpetrators of child abuse (including sexual abuse).

`(4) CONSIDERATIONS WHEN MAKING GRANTS- In making grants to carry out this subsection, the Secretary shall take into consideration--

`(A) the support for the Urban Indian Organization demonstrated by the child protection authorities in the area, including committees or other services funded under the Indian Child Welfare Act of 1978 (25 U.S.C. 1901 et seq.), if any;

`(B) the capability and expertise demonstrated by the Urban Indian Organization to address the complex problem of child sexual abuse in the community; and

`(C) the assessment required under paragraph (2).

`(g) OTHER GRANTS- The Secretary, acting through the Service, may enter into a contract with or make grants to an Urban Indian Organization that provides or arranges for the provision of health care services (through satellite facilities, provider networks, or otherwise) to Urban Indians in more than 1 Urban Center.

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

`(a) GRANTS AND CONTRACTS AUTHORIZED- Under authority of the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'), the Secretary, acting through the Service, may enter into contracts with or make grants to Urban Indian Organizations situated in Urban Centers for which contracts have not been entered into or grants have not been made under section 503.

`(b) PURPOSE- The purpose of a contract or grant made under this section shall be the determination of the matters described in subsection (c)(1) in order to assist the Secretary in assessing the health status and health care needs of Urban Indians in the Urban Center involved and determining whether the Secretary should enter into a contract or make a grant under section 503 with respect to the Urban Indian Organization which the Secretary has entered into a contract with, or made a grant to, under this section.

`(c) GRANT AND CONTRACT REQUIREMENTS- Any contract entered into, or grant made, by the Secretary under this section shall include requirements that--

`(1) the Urban Indian Organization successfully undertakes to--

`(A) document the health care status and unmet health care needs of Urban Indians in the Urban Center involved; and

`(B) with respect to Urban Indians in the Urban Center involved, determine the matters described in paragraphs (2), (3), (4), and (7) of section 503(b); and

`(2) the Urban Indian Organization complete performance of the contract, or carry out the requirements of the grant, within 1 year after the date on which the Secretary and such organization enter into such contract, or within 1 year after such organization receives such grant, whichever is applicable.

`(d) NO RENEWALS- The Secretary may not renew any contract entered into or grant made under this section.

`SEC. 505. EVALUATIONS; RENEWALS.

`(a) PROCEDURES FOR EVALUATIONS- The Secretary, acting through the Service, shall develop procedures to evaluate compliance with grant requirements and compliance with and performance of contracts entered into by Urban Indian Organizations under this title. Such procedures shall include provisions for carrying out the requirements of this section.

`(b) EVALUATIONS- The Secretary, acting through the Service, shall evaluate the compliance of each Urban Indian Organization which has entered into a contract or received a grant under section 503 with the terms of such contract or grant. For purposes of this evaluation, in determining the capacity of an Urban Indian Organization to deliver quality patient care the Secretary shall--

`(1) acting through the Service, conduct an annual onsite evaluation of the organization; or

`(2) accept in lieu of such onsite evaluation evidence of the organization's provisional or full accreditation by a private independent entity recognized by the Secretary for purposes of conducting quality reviews of providers participating in the Medicare program under title XVIII of the Social Security Act.

`(c) NONCOMPLIANCE; UNSATISFACTORY PERFORMANCE- If, as a result of the evaluations conducted under this section, the Secretary determines that an Urban Indian Organization has not complied with the requirements of a grant or complied with or satisfactorily performed a contract under section 503, the Secretary shall, prior to renewing such contract or grant, attempt to resolve with the organization the areas of noncompliance or unsatisfactory performance and modify the contract or grant to prevent future occurrences of noncompliance or unsatisfactory performance. If the Secretary determines that the noncompliance or unsatisfactory performance cannot be resolved and prevented in the future, the Secretary shall not renew the contract or grant with the organization and is authorized to enter into a contract or make a grant under section 503 with another Urban Indian Organization which is situated in the same Urban Center as the Urban Indian Organization whose contract or grant is not renewed under this section.

`(d) CONSIDERATIONS FOR RENEWALS- In determining whether to renew a contract or grant with an Urban Indian Organization under section 503 which has completed performance of a contract or grant under section 504, the Secretary shall review the records of the Urban Indian Organization, the reports submitted under section 507, and shall consider the results of the onsite evaluations or accreditations under subsection (b).

`SEC. 506. OTHER CONTRACT AND GRANT REQUIREMENTS.

`(a) PROCUREMENT- Contracts with Urban Indian Organizations entered into pursuant to this title shall be in accordance with all Federal contracting laws and regulations relating to procurement except that in the discretion of the Secretary, such contracts may be negotiated without advertising and need not conform to the provisions of sections 1304 and 3131 through 3133 of title 40, United States Code.

`(b) PAYMENTS UNDER CONTRACTS OR GRANTS- Payments under any contracts or grants pursuant to this title shall, notwithstanding any term or condition of such contract or grant--

`(1) be made in their entirety by the Secretary to the Urban Indian Organization by no later than the end of the first 30 days of the funding period with respect to which the payments apply, unless the Secretary determines through an evaluation under section 505 that the organization is not capable of administering such payments in their entirety; and

`(2) if any portion thereof is unexpended by the Urban Indian Organization during the funding period with respect to which the payments initially apply, shall be carried forward for expenditure with respect to allowable or reimbursable costs incurred by the organization during 1 or more subsequent funding periods without additional justification or documentation by the organization as a condition of carrying forward the availability for expenditure of such funds.

`(c) REVISION OR AMENDMENT OF CONTRACTS- Notwithstanding any provision of law to the contrary, the Secretary may, at the request or consent of an Urban Indian Organization, revise or amend any contract entered into by the Secretary with such organization under this title as necessary to carry out the purposes of this title.

`(d) FAIR AND UNIFORM SERVICES AND ASSISTANCE- Contracts with or grants to Urban Indian Organizations and regulations adopted pursuant to this title shall include provisions to assure the fair and uniform provision to Urban Indians of services and assistance under such contracts or grants by such organizations.

`SEC. 507. REPORTS AND RECORDS.

`(a) REPORTS- For each fiscal year during which an Urban Indian Organization receives or expends funds pursuant to a contract entered into or a grant received pursuant to this title, such Urban Indian Organization shall submit to the Secretary not more frequently than every 6 months, a report that includes the following:

`(1) In the case of a contract or grant under section 503, recommendations pursuant to section 503(a)(5).

`(2) Information on activities conducted by the organization pursuant to the contract or grant.

`(3) An accounting of the amounts and purpose for which Federal funds were expended.

`(4) A minimum set of data, using uniformly defined elements, that is specified by the Secretary in consultation, consistent with section 514, with Urban Indian Organizations.

`(b) AUDIT- The reports and records of the Urban Indian Organization with respect to a contract or grant under this title shall be subject to audit by the Secretary and the Comptroller General of the United States.

`(c) COSTS OF AUDITS- The Secretary shall allow as a cost of any contract or grant entered into or awarded under section 502 or 503 the cost of an annual independent financial audit conducted by--

`(1) a certified public accountant; or

`(2) a certified public accounting firm qualified to conduct Federal compliance audits.

`SEC. 508. LIMITATION ON CONTRACT AUTHORITY.

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

`SEC. 509. FACILITIES.

`(a) GRANTS- The Secretary, acting through the Service, may make grants to contractors or grant recipients under this title for the lease, purchase, renovation, construction, or expansion of facilities, including leased facilities, in order to assist such contractors or grant recipients in complying with applicable licensing or certification requirements.

`(b) LOANS- The Secretary, acting through the Services may carry out a study to determine the feasibility of establishing a loan fund to provide to Urban Indian Organizations direct loans or guarantees for loans for the construction of health care facilities in a manner consistent with section 309.

`SEC. 510. DIVISION OF URBAN INDIAN HEALTH.

`There is hereby established within the Service a Division of Urban Indian Health, which shall be responsible for--

`(1) carrying out the provisions of this title;

`(2) providing central oversight of the programs and services authorized under this title; and

`(3) providing technical assistance to Urban Indian Organizations.

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

`(a) GRANTS AUTHORIZED- The Secretary, acting through the Service, may make grants for the provision of health-related services in prevention of, treatment of, rehabilitation of, or school- and community-based education regarding, alcohol and substance abuse in Urban Centers to those Urban Indian Organizations with which the Secretary has entered into a contract under this title or under section 201.

`(b) GOALS- Each grant made pursuant to subsection (a) shall set forth the goals to be accomplished pursuant to the grant. The goals shall be specific to each grant as agreed to between the Secretary and the grantee.

`(c) CRITERIA- The Secretary shall establish criteria for the grants made under subsection (a), including criteria relating to the following:

`(1) The size of the Urban Indian population.

`(2) Capability of the organization to adequately perform the activities required under the grant.

`(3) Satisfactory performance standards for the organization in meeting the goals set forth in such grant. The standards shall be negotiated and agreed to between the Secretary and the grantee on a grant-by-grant basis.

`(4) Identification of the need for services.

`(d) ALLOCATION OF GRANTS- The Secretary shall develop a methodology for allocating grants made pursuant to this section based on the criteria established pursuant to subsection (c).

`(e) GRANTS SUBJECT TO CRITERIA- Any funds received by an Urban Indian Organization under this Act for substance abuse prevention, treatment, and rehabilitation shall be subject to the criteria set forth in subsection (c).

`SEC. 512. TREATMENT OF CERTAIN DEMONSTRATION PROJECTS.

`Notwithstanding any other provision of law, the Tulsa Clinic and Oklahoma City Clinic demonstration projects shall--

`(1) be permanent programs within the Service's direct care program;

`(2) continue to be treated as Service Units in the allocation of resources and coordination of care; and

`(3) continue to meet the requirements and definitions of an urban Indian organization in this Act, and shall not be subject to the provisions of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.).

`SEC. 513. URBAN NIAAA TRANSFERRED PROGRAMS.

`(a) GRANTS AND CONTRACTS- The Secretary, through the Office of Urban Indian Health, shall make grants or enter into contracts with Urban Indian Organizations, to take effect not later than September 30, 2008, for the administration of Urban Indian alcohol programs that were originally established under the National Institute on Alcoholism and Alcohol Abuse (hereafter in this section referred to as `NIAAA') and transferred to the Service.

`(b) USE OF FUNDS- Grants provided or contracts entered into under this section shall be used to provide support for the continuation of alcohol prevention and treatment services for Urban Indian populations and such other objectives as are agreed upon between the Service and a recipient of a grant or contract under this section.

`(c) ELIGIBILITY- Urban Indian Organizations that operate Indian alcohol programs originally funded under the NIAAA and subsequently transferred to the Service are eligible for grants or contracts under this section.

`(d) REPORT- The Secretary shall evaluate and report to Congress on the activities of programs funded under this section not less than every 5 years.

`SEC. 514. CONSULTATION WITH URBAN INDIAN ORGANIZATIONS.

`(a) IN GENERAL- The Secretary shall ensure that the Service consults, to the greatest extent practicable, with Urban Indian Organizations.

`(b) DEFINITION OF CONSULTATION- For purposes of subsection (a), consultation is the open and free exchange of information and opinions which leads to mutual understanding and comprehension and which emphasizes trust, respect, and shared responsibility.

`SEC. 515. URBAN YOUTH TREATMENT CENTER DEMONSTRATION.

`(a) CONSTRUCTION AND OPERATION- The Secretary, acting through the Service, through grant or contract, is authorized to fund the construction and operation of at least 2 residential treatment centers in each State described in subsection (b) to demonstrate the provision of alcohol and substance abuse treatment services to Urban Indian youth in a culturally competent residential setting.

`(b) DEFINITION OF STATE- A State described in this subsection is a State in which--

`(1) there resides Urban Indian youth with need for alcohol and substance abuse treatment services in a residential setting; and

`(2) there is a significant shortage of culturally competent residential treatment services for Urban Indian youth.

`SEC. 516. USE OF FEDERAL GOVERNMENT FACILITIES AND SOURCES OF SUPPLY.

`(a) AUTHORIZATION FOR USE- The Secretary, acting through the Service, shall allow an Urban Indian Organization that has entered into a contract or received a grant pursuant to this title, in carrying out such contract or grant, to use existing facilities and all equipment therein or pertaining thereto and other real and personal property owned by the Federal Government within the Secretary's jurisdiction under such terms and conditions as may be agreed upon for their use and maintenance.

`(b) DONATIONS- Subject to subsection (d), the Secretary may donate to an Urban Indian Organization that has entered into a contract or received a grant pursuant to this title any personal or real property determined to be excess to the needs of the Service or the General Services Administration for purposes of carrying out the contract or grant.

`(c) ACQUISITION OF PROPERTY FOR DONATION- The Secretary may acquire excess or surplus government personal or real property for donation (subject to subsection (d)), to an Urban Indian Organization that has entered into a contract or received a grant pursuant to this title if the Secretary determines that the property is appropriate for use by the Urban Indian Organization for a purpose for which a contract or grant is authorized under this title.

`(d) PRIORITY- In the event that the Secretary receives a request for donation of a specific item of personal or real property described in subsection (b) or (c) from both an Urban Indian Organization and from an Indian Tribe or Tribal Organization, the Secretary shall give priority to the request for donation of the Indian Tribe or Tribal Organization if the Secretary receives the request from the Indian Tribe or Tribal Organization before the date the Secretary transfers title to the property or, if earlier, the date the Secretary transfers the property physically to the Urban Indian Organization.

`(e) URBAN INDIAN ORGANIZATIONS DEEMED EXECUTIVE AGENCY FOR CERTAIN PURPOSES- For purposes of section 501 of title 40, United States Code, (relating to Federal sources of supply, including lodging providers, airlines, and other transportation providers), an Urban Indian Organization that has entered into a contract or received a grant pursuant to this title shall be deemed an executive agency when carrying out such contract or grant.

`SEC. 517. GRANTS FOR DIABETES PREVENTION, TREATMENT, AND CONTROL.

`(a) GRANTS AUTHORIZED- The Secretary may make grants to those Urban Indian Organizations that have entered into a contract or have received a grant under this title for the provision of services for the prevention and treatment of, and control of the complications resulting from, diabetes among Urban Indians.

`(b) GOALS- Each grant made pursuant to subsection (a) shall set forth the goals to be accomplished under the grant. The goals shall be specific to each grant as agreed to between the Secretary and the grantee.

`(c) ESTABLISHMENT OF CRITERIA- The Secretary shall establish criteria for the grants made under subsection (a) relating to--

`(1) the size and location of the Urban Indian population to be served;

`(2) the need for prevention of and treatment of, and control of the complications resulting from, diabetes among the Urban Indian population to be served;

`(3) performance standards for the organization in meeting the goals set forth in such grant that are negotiated and agreed to by the Secretary and the grantee;

`(4) the capability of the organization to adequately perform the activities required under the grant; and

`(5) the willingness of the organization to collaborate with the registry, if any, established by the Secretary under section 204(e) in the Area Office of the Service in which the organization is located.

`(d) FUNDS SUBJECT TO CRITERIA- Any funds received by an Urban Indian Organization under this Act for the prevention, treatment, and control of diabetes among Urban Indians shall be subject to the criteria developed by the Secretary under subsection (c).

`SEC. 518. COMMUNITY HEALTH REPRESENTATIVES.

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

`SEC. 519. EFFECTIVE DATE.

`The amendments made by the Indian Health Care Improvement Act Amendments of 2006 to this title shall take effect beginning on the date of enactment of that Act, regardless of whether the Secretary has promulgated regulations implementing such amendments.

`SEC. 520. ELIGIBILITY FOR SERVICES.

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

`SEC. 521. AUTHORIZATION OF APPROPRIATIONS.

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

`TITLE VI--ORGANIZATIONAL IMPROVEMENTS

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

`(a) ESTABLISHMENT-

`(1) IN GENERAL- In order to more effectively and efficiently carry out the responsibilities, authorities, and functions of the United States to provide health care services to Indians and Indian Tribes, as are or may be hereafter provided by Federal statute or treaties, there is established within the Public Health Service of the Department the Indian Health Service.

`(2) ASSISTANT SECRETARY OF INDIAN HEALTH- The Service shall be administered by an Assistant Secretary of Indian Health, who shall be appointed by the President, by and with the advice and consent of the Senate. The Assistant Secretary shall report to the Secretary. Effective with respect to an individual appointed by the President, by and with the advice and consent of the Senate, after January 1, 2005, the term of service of the Assistant Secretary shall be 4 years. An Assistant Secretary may serve more than 1 term.

`(3) INCUMBENT- The individual serving in the position of Director of the Indian Health Service on the day before the date of enactment of the Indian Health Care Improvement Act Amendments of 2006 shall serve as Assistant Secretary.

`(4) ADVOCACY AND CONSULTATION- The position of Assistant Secretary is established to, in a manner consistent with the government-to-government relationship between the United States and Indian Tribes--

`(A) facilitate advocacy for the development of appropriate Indian health policy; and

`(B) promote consultation on matters relating to Indian health.

`(b) AGENCY- The Service shall be an agency within the Public Health Service of the Department, and shall not be an office, component, or unit of any other agency of the Department.

`(c) DUTIES- The Assistant Secretary of Indian Health shall--

`(1) perform all functions that were, on the day before the date of enactment of the Indian Health Care Improvement Act Amendments of 2006, carried out by or under the direction of the individual serving as Director of the Service on that day;

`(2) perform all functions of the Secretary relating to the maintenance and operation of hospital and health facilities for Indians and the planning for, and provision and utilization of, health services for Indians;

`(3) administer all health programs under which health care is provided to Indians based upon their status as Indians which are administered by the Secretary, including programs under--

`(A) this Act;

`(B) the Act of November 2, 1921 (25 U.S.C. 13);

`(C) the Act of August 5, 1954 (42 U.S.C. 2001 et seq.);

`(D) the Act of August 16, 1957 (42 U.S.C. 2005 et seq.); and

`(E) the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.);

`(4) administer all scholarship and loan functions carried out under title I;

`(5) report directly to the Secretary concerning all policy- and budget-related matters affecting Indian health;

`(6) collaborate with the Assistant Secretary for Health concerning appropriate matters of Indian health that affect the agencies of the Public Health Service;

`(7) advise each Assistant Secretary of the Department concerning matters of Indian health with respect to which that Assistant Secretary has authority and responsibility;

`(8) advise the heads of other agencies and programs of the Department concerning matters of Indian health with respect to which those heads have authority and responsibility;

`(9) coordinate the activities of the Department concerning matters of Indian health; and

`(10) perform such other functions as the Secretary may designate.

`(d) AUTHORITY-

`(1) IN GENERAL- The Secretary, acting through the Assistant Secretary, shall have the authority--

`(A) except to the extent provided for in paragraph (2), to appoint and compensate employees for the Service in accordance with title 5, United States Code;

`(B) to enter into contracts for the procurement of goods and services to carry out the functions of the Service; and

`(C) to manage, expend, and obligate all funds appropriated for the Service.

`(2) PERSONNEL ACTIONS- Notwithstanding any other provision of law, the provisions of section 12 of the Act of June 18, 1934 (48 Stat. 986; 25 U.S.C. 472), shall apply to all personnel actions taken with respect to new positions created within the Service as a result of its establishment under subsection (a).

`(e) REFERENCES- Any reference to the Director of the Indian Health Service in any Federal law, Executive order, rule, regulation, or delegation of authority, or in any document of or relating to the Director of the Indian Health Service, shall be deemed to refer to the Assistant Secretary.

`SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYSTEM.

`(a) ESTABLISHMENT-

`(1) IN GENERAL- The Secretary shall establish an automated management information system for the Service.

`(2) REQUIREMENTS OF SYSTEM- The information system established under paragraph (1) shall include--

`(A) a financial management system;

`(B) a patient care information system for each area served by the Service;

`(C) a privacy component that protects the privacy of patient information held by, or on behalf of, the Service;

`(D) a services-based cost accounting component that provides estimates of the costs associated with the provision of specific medical treatments or services in each Area office of the Service;

`(E) an interface mechanism for patient billing and accounts receivable system; and

`(F) a training component.

`(b) PROVISION OF SYSTEMS TO TRIBES AND ORGANIZATIONS- The Secretary shall provide each Tribal Health Program automated management information systems which--

`(1) meet the management information needs of such Tribal Health Program with respect to the treatment by the Tribal Health Program of patients of the Service; and

`(2) meet the management information needs of the Service.

`(c) ACCESS TO RECORDS- Notwithstanding any other provision of law, each patient shall have reasonable access to the medical or health records of such patient which are held by, or on behalf of, the Service.

`(d) AUTHORITY TO ENHANCE INFORMATION TECHNOLOGY- The Secretary, acting through the Assistant Secretary, shall have the authority to enter into contracts, agreements, or joint ventures with other Federal agencies, States, and private and nonprofit organizations, for the purpose of enhancing information technology in Indian health programs and facilities.

`SEC. 603. AUTHORIZATION OF APPROPRIATIONS.

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

`TITLE VII--BEHAVIORAL HEALTH PROGRAMS

`SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREATMENT SERVICES.

`(a) PURPOSES- The purposes of this section are as follows:

`(1) To authorize and direct the Secretary, acting through the Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, to develop a comprehensive behavioral health prevention and treatment program which emphasizes collaboration among alcohol and substance abuse, social services, and mental health programs.

`(2) To provide information, direction, and guidance relating to mental illness and dysfunction and self-destructive behavior, including child abuse and family violence, to those Federal, tribal, State, and local agencies responsible for programs in Indian communities in areas of health care, education, social services, child and family welfare, alcohol and substance abuse, law enforcement, and judicial services.

`(3) To assist Indian Tribes to identify services and resources available to address mental illness and dysfunctional and self-destructive behavior.

`(4) To provide authority and opportunities for Indian Tribes and Tribal Organizations to develop, implement, and coordinate with community-based programs which include identification, prevention, education, referral, and treatment services, including through multidisciplinary resource teams.

`(5) To ensure that Indians, as citizens of the United States and of the States in which they reside, have the same access to behavioral health services to which all citizens have access.

`(6) To modify or supplement existing programs and authorities in the areas identified in paragraph (2).

`(b) PLANS-

`(1) DEVELOPMENT- The Secretary, acting through the Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, shall encourage Indian Tribes and Tribal Organizations to develop tribal plans, and Urban Indian Organizations to develop local plans, and for all such groups to participate in developing areawide plans for Indian Behavioral Health Services. The plans shall include, to the extent feasible, the following components:

`(A) An assessment of the scope of alcohol or other substance abuse, mental illness, and dysfunctional and self-destructive behavior, including suicide, child abuse, and family violence, among Indians, including--

`(i) the number of Indians served who are directly or indirectly affected by such illness or behavior; or

`(ii) an estimate of the financial and human cost attributable to such illness or behavior.

`(B) An assessment of the existing and additional resources necessary for the prevention and treatment of such illness and behavior, including an assessment of the progress toward achieving the availability of the full continuum of care described in subsection (c).

`(C) An estimate of the additional funding needed by the Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations to meet their responsibilities under the plans.

`(2) NATIONAL CLEARINGHOUSE- The Secretary, acting through the Service, shall establish a national clearinghouse of plans and reports on the outcomes of such plans developed by Indian Tribes, Tribal Organizations, Urban Indian Organizations, and Service Areas relating to behavioral health. The Secretary shall ensure access to these plans and outcomes by any Indian Tribe, Tribal Organization, Urban Indian Organization, or the Service.

`(3) TECHNICAL ASSISTANCE- The Secretary shall provide technical assistance to Indian Tribes, Tribal Organizations, and Urban Indian Organizations in preparation of plans under this section and in developing standards of care that may be used and adopted locally.

`(c) PROGRAMS- The Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, shall provide, to the extent feasible and if funding is available, programs including the following:

`(1) COMPREHENSIVE CARE- A comprehensive continuum of behavioral health care which provides--

`(A) community-based prevention, intervention, outpatient, and behavioral health aftercare;

`(B) detoxification (social and medical);

`(C) acute hospitalization;

`(D) intensive outpatient/day treatment;

`(E) residential treatment;

`(F) transitional living for those needing a temporary, stable living environment that is supportive of treatment and recovery goals;

`(G) emergency shelter;

`(H) intensive case management; and

`(I) diagnostic services.

`(2) CHILD CARE- Behavioral health services for Indians from birth through age 17, including--

`(A) preschool and school age fetal alcohol disorder services, including assessment and behavioral intervention;

`(B) mental health and substance abuse services (emotional, organic, alcohol, drug, inhalant, and tobacco);

`(C) identification and treatment of co-occurring disorders and comorbidity;

`(D) prevention of alcohol, drug, inhalant, and tobacco use;

`(E) early intervention, treatment, and aftercare;

`(F) promotion of healthy choices and lifestyle (related to sexually transmitted diseases, domestic violence, sexual abuse, suicide, teen pregnancy, obesity, and other risk/safety issues); and

`(G) identification and treatment of neglect and physical, mental, and sexual abuse.

`(3) ADULT CARE- Behavioral health services for Indians from age 18 through 55, including--

`(A) early intervention, treatment, and aftercare;

`(B) mental health and substance abuse services (emotional, alcohol, drug, inhalant, and tobacco), including gender specific services;

`(C) identification and treatment of co-occurring disorders (dual diagnosis) and comorbidity;

`(D) promotion of gender specific healthy choices and lifestyle (related to parenting, partners, domestic violence, sexual abuse, suicide, obesity, and other risk-related behavior);

`(E) treatment services for women at risk of giving birth to a child with a fetal alcohol disorder; and

`(F) gender specific treatment for sexual assault and domestic violence.

`(4) FAMILY CARE- Behavioral health services for families, including--

`(A) early intervention, treatment, and aftercare for affected families;

`(B) treatment for sexual assault and domestic violence; and

`(C) promotion of healthy choices and lifestyle (related to parenting, partners, domestic violence, and other abuse issues).

`(5) ELDER CARE- Behavioral health services for Indians 56 years of age and older, including--

`(A) early intervention, treatment, and aftercare;

`(B) mental health and substance abuse services (emotional, alcohol, drug, inhalant, and tobacco), including gender specific services;

`(C) identification and treatment of co-occurring disorders (dual diagnosis) and comorbidity;

`(D) promotion of healthy choices and lifestyle (managing conditions related to aging);

`(E) gender specific treatment for sexual assault, domestic violence, neglect, physical and mental abuse and exploitation; and

`(F) identification and treatment of dementias regardless of cause.

`(d) COMMUNITY BEHAVIORAL HEALTH PLAN-

`(1) ESTABLISHMENT- The governing body of any Indian Tribe, Tribal Organization, or Urban Indian Organization may adopt a resolution for the establishment of a community behavioral health plan providing for the identification and coordination of available resources and programs to identify, prevent, or treat substance abuse, mental illness, or dysfunctional and self-destructive behavior, including child abuse and family violence, among its members or its service population. This plan should include behavioral health services, social services, intensive outpatient services, and continuing aftercare.

`(2) TECHNICAL ASSISTANCE- At the request of an Indian Tribe, Tribal Organization, or Urban Indian Organization, the Bureau of Indian Affairs and the Service shall cooperate with and provide technical assistance to the Indian Tribe, Tribal Organization, or Urban Indian Organization in the development and implementation of such plan.

`(3) FUNDING- The Secretary, acting through the Service, may make funding available to Indian Tribes and Tribal Organizations which adopt a resolution pursuant to paragraph (1) to obtain technical assistance for the development of a community behavioral health plan and to provide administrative support in the implementation of such plan.

`(e) COORDINATION FOR AVAILABILITY OF SERVICES- The Secretary, acting through the Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, shall coordinate behavioral health planning, to the extent feasible, with other Federal agencies and with State agencies, to encourage comprehensive behavioral health services for Indians regardless of their place of residence.

`(f) MENTAL HEALTH CARE NEED ASSESSMENT- Not later than 1 year after the date of the enactment of the Indian Health Care Improvement Act Amendments of 2006, the Secretary, acting through the Service, shall make an assessment of the need for inpatient mental health care among Indians and the availability and cost of inpatient mental health facilities which can meet such need. In making such assessment, the Secretary shall consider the possible conversion of existing, underused Service hospital beds into psychiatric units to meet such need.

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

`(a) CONTENTS- Not later than 12 months after the date of the enactment of the Indian Health Care Improvement Act Amendments of 2006, the Secretary, acting through the Service, and the Secretary of the Interior shall develop and enter into one or more memoranda of agreement, or review and update any existing memoranda of agreement, as required by section 4205 of the Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 2411) under which the Secretaries address the following:

`(1) The scope and nature of mental illness and dysfunctional and self-destructive behavior, including child abuse and family violence, among Indians.

`(2) The existing Federal, tribal, State, local, and private services, resources, and programs available to provide behavioral health services for Indians.

`(3) The unmet need for additional services, resources, and programs necessary to meet the needs identified pursuant to paragraph (1).

`(4)(A) The right of Indians, as citizens of the United States and of the States in which they reside, to have access to behavioral health services to which all citizens have access.

`(B) The right of Indians to participate in, and receive the benefit of, such services.

`(C) The actions necessary to protect the exercise of such right.

`(5) The responsibilities of the Bureau of Indian Affairs and the Service, including mental illness identification, prevention, education, referral, and treatment services (including services through multidisciplinary resource teams), at the central, area, and agency and Service Unit, Service Area, and headquarters levels to address the problems identified in paragraph (1).

`(6) A strategy for the comprehensive coordination of the behavioral health services provided by the Bureau of Indian Affairs and the Service to meet the problems identified pursuant to paragraph (1), including--

`(A) the coordination of alcohol and substance abuse programs of the Service, the Bureau of Indian Affairs, and Indian Tribes and Tribal Organizations (developed under the Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986) with behavioral health initiatives pursuant to this Act, particularly with respect to the referral and treatment of dually diagnosed individuals requiring behavioral health and substance abuse treatment; and

`(B) ensuring that the Bureau of Indian Affairs and Service programs and services (including multidisciplinary resource teams) addressing child abuse and family violence are coordinated with such non-Federal programs and services.

`(7) Directing appropriate officials of the Bureau of Indian Affairs and the Service, particularly at the agency and Service Unit levels, to cooperate fully with tribal requests made pursuant to community behavioral health plans adopted under section 701(c) and section 4206 of the Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 2412).

`(8) Providing for an annual review of such agreement by the Secretaries which shall be provided to Congress and Indian Tribes and Tribal Organizations.

`(b) SPECIFIC PROVISIONS REQUIRED- The memoranda of agreement updated or entered into pursuant to subsection (a) shall include specific provisions pursuant to which the Service shall assume responsibility for--

`(1) the determination of the scope of the problem of alcohol and substance abuse among Indians, including the number of Indians within the jurisdiction of the Service who are directly or indirectly affected by alcohol and substance abuse and the financial and human cost;

`(2) an assessment of the existing and needed resources necessary for the prevention of alcohol and substance abuse and the treatment of Indians affected by alcohol and substance abuse; and

`(3) an estimate of the funding necessary to adequately support a program of prevention of alcohol and substance abuse and treatment of Indians affected by alcohol and substance abuse.

`(c) CONSULTATION- The Secretary, acting through the Service, and the Secretary of the Interior shall, in developing the memoranda of agreement under subsection (a), consult with and solicit the comments from--

`(1) Indian Tribes and Tribal Organizations;

`(2) Indians;

`(3) Urban Indian Organizations and other Indian organizations; and

`(4) behavioral health service providers.

`(d) PUBLICATION- Each memorandum of agreement entered into or renewed (and amendments or modifications thereto) under subsection (a) shall be published in the Federal Register. At the same time as publication in the Federal Register, the Secretary shall provide a copy of each such memorandum, amendment, or modification to each Indian Tribe, Tribal Organization, and Urban Indian Organization.

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

`(a) ESTABLISHMENT-

`(1) IN GENERAL- The Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, shall provide a program of comprehensive behavioral health, prevention, treatment, and aftercare, including Traditional Health Care Practices, which shall include--

`(A) prevention, through educational intervention, in Indian communities;

`(B) acute detoxification, psychiatric hospitalization, residential, and intensive outpatient treatment;

`(C) community-based rehabilitation and aftercare;

`(D) community education and involvement, including extensive training of health care, educational, and community-based personnel;

`(E) specialized residential treatment programs for high-risk populations, including pregnant and postpartum women and their children; and

`(F) diagnostic services.

`(2) TARGET POPULATIONS- The target population of such programs shall be members of Indian Tribes. Efforts to train and educate key members of the Indian community shall also target employees of health, education, judicial, law enforcement, legal, and social service programs.

`(b) CONTRACT HEALTH SERVICES-

`(1) IN GENERAL- The Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, may enter into contracts with public or private providers of behavioral health treatment services for the purpose of carrying out the program required under subsection (a).

`(2) PROVISION OF ASSISTANCE- In carrying out this subsection, the Secretary shall provide assistance to Indian Tribes and Tribal Organizations to develop criteria for the certification of behavioral health service providers and accreditation of service facilities which meet minimum standards for such services and facilities.

`SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM.

`(a) IN GENERAL- Under the authority of the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'), the Secretary shall establish and maintain a mental health technician program within the Service which--

`(1) provides for the training of Indians as mental health technicians; and

`(2) employs such technicians in the provision of community-based mental health care that includes identification, prevention, education, referral, and treatment services.

`(b) PARAPROFESSIONAL TRAINING- In carrying out subsection (a), the Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, shall provide high-standard paraprofessional training in mental health care necessary to provide quality care to the Indian communities to be served. Such training shall be based upon a curriculum developed or approved by the Secretary which combines education in the theory of mental health care with supervised practical experience in the provision of such care.

`(c) SUPERVISION AND EVALUATION OF TECHNICIANS- The Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, shall supervise and evaluate the mental health technicians in the training program.

`(d) TRADITIONAL HEALTH CARE PRACTICES- The Secretary, acting through the Service, shall ensure that the program established pursuant to this subsection involves the use and promotion of the Traditional Health Care Practices of the Indian Tribes to be served.

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

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

`SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS.

`(a) FUNDING- The Secretary, consistent with section 701, shall make funds available to Indian Tribes, Tribal Organizations, and Urban Indian Organizations to develop and implement a comprehensive behavioral health program of prevention, intervention, treatment, and relapse prevention services that specifically addresses the spiritual, cultural, historical, social, and child care needs of Indian women, regardless of age.

`(b) USE OF GRANT- A grant made available pursuant to this section may be used to--

`(1) develop and provide community training, education, and prevention programs for Indian women relating to behavioral health issues, including fetal alcohol disorders;

`(2) identify and provide psychological services, counseling, advocacy, support, and relapse prevention to Indian women and their families; and

`(3) develop prevention and intervention models for Indian women which incorporate Traditional Health Care Practices, cultural values, and community and family involvement.

`(c) CRITERIA- The Secretary, in consultation with Indian Tribes and Tribal Organizations, shall establish criteria for the review and approval of applications and proposals for funding under this section.

`(d) EARMARK OF CERTAIN FUNDS- Twenty percent of the funds appropriated pursuant to this section shall be used to make grants to Urban Indian Organizations.

`SEC. 707. INDIAN YOUTH PROGRAM.

`(a) DETOXIFICATION AND REHABILITATION- The Secretary, acting through the Service, consistent with section 701, shall develop and implement a program for acute detoxification and treatment for Indian youths, including behavioral health services. The program shall include regional treatment centers designed to include detoxification and rehabilitation for both sexes on a referral basis and programs developed and implemented by Indian Tribes or Tribal Organizations at the local level under the Indian Self-Determination and Education Assistance Act. Regional centers shall be integrated with the intake and rehabilitation programs based in the referring Indian community.

`(b) ALCOHOL AND SUBSTANCE ABUSE TREATMENT CENTERS OR FACILITIES-

`(1) ESTABLISHMENT-

`(A) IN GENERAL- The Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, shall construct, renovate, or, as necessary, purchase, and appropriately staff and operate, at least 1 youth regional treatment center or treatment network in each area under the jurisdiction of an Area Office.

`(B) AREA OFFICE IN CALIFORNIA- For the purposes of this subsection, the Area Office in California shall be considered to be 2 Area Offices, 1 office whose jurisdiction shall be considered to encompass the northern area of the State of California, and 1 office whose jurisdiction shall be considered to encompass the remainder of the State of California for the purpose of implementing California treatment networks.

`(2) FUNDING- For the purpose of staffing and operating such centers or facilities, funding shall be pursuant to the Act of November 2, 1921 (25 U.S.C. 13).

`(3) LOCATION- A youth treatment center constructed or purchased under this subsection shall be constructed or purchased at a location within the area described in paragraph (1) agreed upon (by appropriate tribal resolution) by a majority of the Indian Tribes to be served by such center.

`(4) SPECIFIC PROVISION OF FUNDS-

`(A) IN GENERAL- Notwithstanding any other provision of this title, the Secretary may, from amounts authorized to be appropriated for the purposes of carrying out this section, make funds available to--

`(i) the Tanana Chiefs Conference, Incorporated, for the purpose of leasing, constructing, renovating, operating, and maintaining a residential youth treatment facility in Fairbanks, Alaska; and

`(B) PROVISION OF SERVICES TO ELIGIBLE YOUTHS- Until additional residential youth treatment facilities are established in Alaska pursuant to this section, the facilities specified in subparagraph (A) shall make every effort to provide services to all eligible Indian youths residing in Alaska.

`(c) INTERMEDIATE ADOLESCENT BEHAVIORAL HEALTH SERVICES-

`(1) IN GENERAL- The Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, may provide intermediate behavioral health services, which may incorporate Traditional Health Care Practices, to Indian children and adolescents, including--

`(A) pretreatment assistance;

`(B) inpatient, outpatient, and aftercare services;

`(C) emergency care;

`(D) suicide prevention and crisis intervention; and

`(E) prevention and treatment of mental illness and dysfunctional and self-destructive behavior, including child abuse and family violence.

`(2) USE OF FUNDS- Funds provided under this subsection may be used--

`(A) to construct or renovate an existing health facility to provide intermediate behavioral health services;

`(B) to hire behavioral health professionals;

`(C) to staff, operate, and maintain an intermediate mental health facility, group home, sober housing, transitional housing or similar facilities, or youth shelter where intermediate behavioral health services are being provided;

`(D) to make renovations and hire appropriate staff to convert existing hospital beds into adolescent psychiatric units; and

`(E) for intensive home- and community-based services.

`(3) CRITERIA- The Secretary, acting through the Service, shall, in consultation with Indian Tribes and Tribal Organizations, establish criteria for the review and approval of applications or proposals for funding made available pursuant to this subsection.

`(d) FEDERALLY OWNED STRUCTURES-

`(1) IN GENERAL- The Secretary, in consultation with Indian Tribes and Tribal Organizations, shall--

`(A) identify and use, where appropriate, federally owned structures suitable for local residential or regional behavioral health treatment for Indian youths; and

`(B) establish guidelines, in consultation with Indian Tribes and Tribal Organizations, for determining the suitability of any such federally owned structure to be used for local residential or regional behavioral health treatment for Indian youths.

`(2) TERMS AND CONDITIONS FOR USE OF STRUCTURE- Any structure described in paragraph (1) may be used under such terms and conditions as may be agreed upon by the Secretary and the agency having responsibility for the structure and any Indian Tribe or Tribal Organization operating the program.

`(e) REHABILITATION AND AFTERCARE SERVICES-

`(1) IN GENERAL- The Secretary, Indian Tribes, or Tribal Organizations, in cooperation with the Secretary of the Interior, shall develop and implement within each Service Unit, community-based rehabilitation and follow-up services for Indian youths who are having significant behavioral health problems, and require long-term treatment, community reintegration, and monitoring to support the Indian youths after their return to their home community.

`(2) ADMINISTRATION- Services under paragraph (1) shall be provided by trained staff within the community who can assist the Indian youths in their continuing development of self-image, positive problem-solving skills, and nonalcohol or substance abusing behaviors. Such staff may include alcohol and substance abuse counselors, mental health professionals, and other health professionals and paraprofessionals, including community health representatives.

`(f) INCLUSION OF FAMILY IN YOUTH TREATMENT PROGRAM- In providing the treatment and other services to Indian youths authorized by this section, the Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, shall provide for the inclusion of family members of such youths in the treatment programs or other services as may be appropriate. Not less than 10 percent of the funds appropriated for the purposes of carrying out subsection (e) shall be used for outpatient care of adult family members related to the treatment of an Indian youth under that subsection.

`(g) MULTIDRUG ABUSE PROGRAM- The Secretary, acting through the Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, shall provide, consistent with section 701, programs and services to prevent and treat the abuse of multiple forms of substances, including alcohol, drugs, inhalants, and tobacco, among Indian youths residing in Indian communities, on or near reservations, and in urban areas and provide appropriate mental health services to address the incidence of mental illness among such youths.

`SEC. 708. INPATIENT AND COMMUNITY-BASED MENTAL HEALTH FACILITIES DESIGN, CONSTRUCTION, AND STAFFING.

`Not later than 1 year after the date of the enactment of the Indian Health Care Improvement Act Amendments of 2006, the Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, may provide, in each area of the Service, not less than 1 inpatient mental health care facility, or the equivalent, for Indians with behavioral health problems. For the purposes of this subsection, California shall be considered to be 2 Area Offices, 1 office whose location shall be considered to encompass the northern area of the State of California and 1 office whose jurisdiction shall be considered to encompass the remainder of the State of California. The Secretary shall consider the possible conversion of existing, underused Service hospital beds into psychiatric units to meet such need.

`SEC. 709. TRAINING AND COMMUNITY EDUCATION.

`(a) PROGRAM- The Secretary, in cooperation with the Secretary of the Interior, shall develop and implement or provide funding for Indian Tribes and Tribal Organizations to develop and implement, within each Service Unit or tribal program, a program of community education and involvement which shall be designed to provide concise and timely information to the community leadership of each tribal community. Such program shall include education about behavioral health issues to political leaders, Tribal judges, law enforcement personnel, members of tribal health and education boards, health care providers including traditional practitioners, and other critical members of each tribal community. Community-based training (oriented toward local capacity development) shall also include tribal community provider training (designed for adult learners from the communities receiving services for prevention, intervention, treatment, and aftercare).

`(b) INSTRUCTION- The Secretary, acting through the Service, shall, either directly or through Indian Tribes and Tribal Organizations, provide instruction in the area of behavioral health issues, including instruction in crisis intervention and family relations in the context of alcohol and substance abuse, child sexual abuse, youth alcohol and substance abuse, and the causes and effects of fetal alcohol disorders to appropriate employees of the Bureau of Indian Affairs and the Service, and to personnel in schools or programs operated under any contract with the Bureau of Indian Affairs or the Service, including supervisors of emergency shelters and halfway houses described in section 4213 of the Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 2433).

`(c) TRAINING MODELS- In carrying out the education and training programs required by this section, the Secretary, in consultation with Indian Tribes, Tribal Organizations, Indian behavioral health experts, and Indian alcohol and substance abuse prevention experts, shall develop and provide community-based training models. Such models shall address--

`(1) the elevated risk of alcohol and behavioral health problems faced by children of alcoholics;

`(2) the cultural, spiritual, and multigenerational aspects of behavioral health problem prevention and recovery; and

`(3) community-based and multidisciplinary strategies for preventing and treating behavioral health problems.

`SEC. 710. BEHAVIORAL HEALTH PROGRAM.

`(a) INNOVATIVE PROGRAMS- The Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, consistent with section 701, may plan, develop, implement, and carry out programs to deliver innovative community-based behavioral health services to Indians.

`(b) FUNDING; CRITERIA- The Secretary may award such funding for a project under subsection (a) to an Indian Tribe or Tribal Organization and may consider the following criteria:

`(1) The project will address significant unmet behavioral health needs among Indians.

`(2) The project will serve a significant number of Indians.

`(3) The project has the potential to deliver services in an efficient and effective manner.

`(4) The Indian Tribe or Tribal Organization has the administrative and financial capability to administer the project.

`(5) The project may deliver services in a manner consistent with traditional Indian healing and treatment practices.

`(6) The project is coordinated with, and avoids duplication of, existing services.

`(c) EQUITABLE TREATMENT- For purposes of this subsection, the Secretary shall, in evaluating applications or proposals for funding for projects to be operated under any contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.), use the same criteria that the Secretary uses in evaluating any other application or proposal for such funding.

`SEC. 711. FETAL ALCOHOL DISORDER PROGRAMS.

`(a) PROGRAMS-

`(1) ESTABLISHMENT- The Secretary, consistent with section 701, acting through the Service, Indian Tribes, and Tribal Organizations, is authorized to establish and operate fetal alcohol disorder programs as provided in this section for the purposes of meeting the health status objectives specified in section 3.

`(2) USE OF FUNDS- Funding provided pursuant to this section shall be used for the following:

`(A) To develop and provide for Indians community and in-school training, education, and prevention programs relating to fetal alcohol disorders.

`(B) To identify and provide behavioral health treatment to high-risk Indian women and high-risk women pregnant with an Indian's child.

`(C) To identify and provide appropriate psychological services, educational and vocational support, counseling, advocacy, and information to fetal alcohol disorder affected Indians and their families or caretakers.

`(D) To develop and implement counseling and support programs in schools for fetal alcohol disorder affected Indian children.

`(E) To develop prevention and intervention models which incorporate traditional healers, cultural and spiritual values, and community involvement.

`(F) To develop, print, and disseminate education and prevention materials on fetal alcohol disorder.

`(G) To develop and implement, through the tribal consultation process, culturally sensitive assessment and diagnostic tools including dysmorphology clinics and multidisciplinary fetal alcohol disorder clinics for use in Indian communities and Urban Centers.

`(H) To develop early childhood intervention projects from birth on to mitigate the effects of fetal alcohol disorder among Indians.

`(I) To develop--

`(i) community-based support services for Indians and women pregnant with Indian children; and

`(ii) to the extent funding is available, community-based housing for adult Indians with fetal alcohol disorder.

`(3) CRITERIA FOR APPLICATIONS- The Secretary shall establish criteria for the review and approval of applications for funding under this section.

`(b) SERVICES- The Secretary, acting through the Service and Indian Tribes, Tribal Organizations, and Urban Indian Organizations, shall--

`(1) develop and provide services for the prevention, intervention, treatment, and aftercare for those affected by fetal alcohol disorder in Indian communities; and

`(2) provide supportive services, directly or through an Indian Tribe, Tribal Organization, or Urban Indian Organization, including services to meet the special educational, vocational, school-to-work transition, and independent living needs of adolescent and adult Indians with fetal alcohol disorder.

`(c) TASK FORCE- The Secretary shall establish a task force to be known as the Fetal Alcohol Disorder Task Force to advise the Secretary in carrying out subsection (b). Such task force shall be composed of representatives from the following:

`(1) The National Institute on Drug Abuse.

`(2) The National Institute on Alcohol and Alcoholism.

`(3) The Office of Substance Abuse Prevention.

`(4) The National Institute of Mental Health.

`(5) The Service.

`(6) The Office of Minority Health of the Department of Health and Human Services.

`(7) The Administration for Native Americans.

`(8) The National Institute of Child Health and Human Development (NICHD).

`(9) The Centers for Disease Control and Prevention.

`(10) The Bureau of Indian Affairs.

`(11) Indian Tribes.

`(12) Tribal Organizations.

`(13) Urban Indian Organizations.

`(14) experts on Indian fetal alcohol disorder.

`(d) APPLIED RESEARCH PROJECTS- The Secretary, acting through the Substance Abuse and Mental Health Services Administration, shall make grants available to Indian Tribes, Tribal Organizations, and Urban Indian Organizations for applied research projects which propose to elevate the understanding of methods to prevent, intervene, treat, or provide rehabilitation and behavioral health aftercare for Indians and Urban Indians affected by fetal alcohol disorder.

`(e) FUNDING FOR URBAN INDIAN ORGANIZATIONS- Ten percent of the funds appropriated pursuant to this section shall be used to make grants to Urban Indian Organizations funded under title V.

`SEC. 712. CHILD SEXUAL ABUSE AND PREVENTION TREATMENT PROGRAMS.

`(a) ESTABLISHMENT- The Secretary, acting through the Service, and the Secretary of the Interior, Indian Tribes, and Tribal Organizations shall establish, consistent with section 701, in every Service Area, programs involving treatment for--

`(1) victims of sexual abuse who are Indian children or children in an Indian household; and

`(2) perpetrators of child sexual abuse who are Indian or members of an Indian household.

`(b) USE OF FUNDS- Funding provided pursuant to this section shall be used for the following:

`(1) To develop and provide community education and prevention programs related to sexual abuse of Indian children or children in an Indian household.

`(2) To identify and provide behavioral health treatment to victims of sexual abuse who are Indian children or children in an Indian household, and to their family members who are affected by sexual abuse.

`(3) To develop prevention and intervention models which incorporate Traditional Health Care Practices, cultural and spiritual values, and community involvement.

`(4) To develop and implement, through the tribal consultation process, culturally sensitive assessment and diagnostic tools for use in Indian communities and Urban Centers.

`(5) To identify and provide behavioral health treatment to Indian perpetrators and perpetrators who are members of an Indian household--

`(A) making efforts to begin offender and behavioral health treatment while the perpetrator is incarcerated or at the earliest possible date if the perpetrator is not incarcerated; and

`(B) providing treatment after the perpetrator is released, until it is determined that the perpetrator is not a threat to children.

`SEC. 713. BEHAVIORAL HEALTH RESEARCH.

`The Secretary, in consultation with appropriate Federal agencies, shall provide funding to Indian Tribes, Tribal Organizations, and Urban Indian Organizations or enter into contracts with, or make grants to appropriate institutions for, the conduct of research on the incidence and prevalence of behavioral health problems among Indians served by the Service, Indian Tribes, or Tribal Organizations and among Indians in urban areas. Research priorities under this section shall include--

`(1) the multifactorial causes of Indian youth suicide, including--

`(A) protective and risk factors and scientific data that identifies those factors; and

`(B) the effects of loss of cultural identity and the development of scientific data on those effects;

`(2) the interrelationship and interdependence of behavioral health problems with alcoholism and other substance abuse, suicide, homicides, other injuries, and the incidence of family violence; and

`(3) the development of models of prevention techniques.

The effect of the interrelationships and interdependencies referred to in paragraph (1) on children, and the development of prevention techniques under paragraph (2) applicable to children, shall be emphasized.

`SEC. 714. DEFINITIONS.

`For the purpose of this title, the following definitions shall apply:

`(1) ASSESSMENT- The term `assessment' means the systematic collection, analysis, and dissemination of information on health status, health needs, and health problems.

`(2) ALCOHOL-RELATED NEURODEVELOPMENTAL DISORDERS OR ARND- The term `alcohol-related neurodevelopmental disorders' or `ARND' means a central nervous system or behavioral disorder, following a maternal history of alcohol consumption during pregnancy, that may involve--

`(A) physical manifestations such as development delay, intellectual deficit, neurologic abnormalities, or failure to thrive as infants; or

`(B) behavioral manifestations such as irritability, or for older children, hyperactivity, attention deficit, language dysfunction, or perceptual or judgment difficulties.

`(3) BEHAVIORAL HEALTH AFTERCARE- The term `behavioral health aftercare' includes those activities and resources used to support recovery following inpatient, residential, intensive substance abuse, or mental health outpatient or outpatient treatment. The purpose is to help prevent or deal with relapse by ensuring that by the time a client or patient is discharged from a level of care, such as outpatient treatment, an aftercare plan has been developed with the client. An aftercare plan may use such resources as a community-based therapeutic group, transitional living facilities, a 12-step sponsor, a local 12-step or other related support group, and other community-based providers (mental health professionals, community health aides, community health representatives, mental health technicians, ministers, etc.).

`(4) DUAL DIAGNOSIS- The term `dual diagnosis' means coexisting substance abuse and mental illness conditions or diagnosis. Such clients are sometimes referred to as mentally ill chemical abusers (MICAs).

`(5) FETAL ALCOHOL DISORDERS- The term `fetal alcohol disorders' means fetal alcohol syndrome, partial fetal alcohol syndrome and alcohol related neurodevelopmental disorder (ARND).

`(6) FETAL ALCOHOL SYNDROME OR FAS- The term `fetal alcohol syndrome' or `FAS' means a syndrome in which, with a history of maternal alcohol consumption during pregnancy, the following criteria are met:

`(A) Central nervous system involvement such as developmental delay, intellectual deficit, microencephaly, or neurologic abnormalities.

`(B) Craniofacial abnormalities with at least 2 of the following: microophthalmia, short palpebral fissures, poorly developed philtrum, thin upper lip, flat nasal bridge, and short upturned nose.

`(C) Prenatal or postnatal growth delay.

`(7) PARTIAL FAS- The term `partial FAS' means, with a history of maternal alcohol consumption during pregnancy, having most of the criteria of FAS, though not meeting a minimum of at least 2 of the following: microophthalmia, short palpebral fissures, poorly developed philtrum, thin upper lip, flat nasal bridge, and short upturned nose.

`(8) REHABILITATION- The term `rehabilitation' means to restore the ability or capacity to engage in usual and customary life activities through education and therapy.

`(9) SUBSTANCE ABUSE- The term `substance abuse' includes inhalant abuse.

`SEC. 715. AUTHORIZATION OF APPROPRIATIONS.

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

`TITLE VIII--MISCELLANEOUS

`SEC. 801. REPORTS.

`The President shall, at the time the budget is submitted under section 1105 of title 31, United States Code, for each fiscal year transmit to Congress a report containing the following:

`(1) A report on the progress made in meeting the objectives of this Act, including a review of programs established or assisted pursuant to this Act and assessments and recommendations of additional programs or additional assistance necessary to, at a minimum, provide health services to Indians and ensure a health status for Indians, which are at a parity with the health services available to and the health status of the general population, including specific comparisons of appropriations provided and those required for such parity.

`(2) A report on whether, and to what extent, new national health care programs, benefits, initiatives, or financing systems have had an impact on the purposes of this Act and any steps that the Secretary may have taken to consult with Indian Tribes, Tribal Organizations, and Urban Indian Organizations to address such impact, including a report on proposed changes in allocation of funding pursuant to section 808.

`(3) A report on the use of health services by Indians--

`(A) on a national and area or other relevant geographical basis;

`(B) by gender and age;

`(C) by source of payment and type of service;

`(D) comparing such rates of use with rates of use among comparable non-Indian populations; and

`(E) provided under contracts.

`(4) A report of contractors to the Secretary on Health Care Educational Loan Repayments every 6 months required by section 110.

`(5) A general audit report of the Secretary on the Health Care Educational Loan Repayment Program as required by section 110(n).

`(6) A report of the findings and conclusions of demonstration programs on development of educational curricula for substance abuse counseling as required in section 126(f).

`(7) A separate statement which specifies the amount of funds requested to carry out the provisions of section 201.

`(8) A report of the evaluations of health promotion and disease prevention as required in section 203(c).

`(9) A biennial report to Congress on infectious diseases as required by section 212.

`(10) A report on environmental and nuclear health hazards as required by section 215.

`(11) An annual report on the status of all health care facilities needs as required by sections 301(c)(2) and 301(d).

`(12) Reports on safe water and sanitary waste disposal facilities as required by section 302(h).

`(13) An annual report on the expenditure of nonservice funds for renovation as required by sections 304(b)(2).

`(14) A report identifying the backlog of maintenance and repair required at Service and tribal facilities required by section 313(a).

`(15) A report providing an accounting of reimbursement funds made available to the Secretary under titles XVIII, XIX, and XXI of the Social Security Act.

`(16) A report on any arrangements for the sharing of medical facilities or services between the Service, Indian Tribes, and Tribal Organizations, and the Department of Veterans Affairs and the Department of Defense, as authorized by section 406.

`(17) A report on evaluation and renewal of Urban Indian programs under section 505.

`(18) A report on the evaluation of programs as required by section 513(d).

`(19) A report on alcohol and substance abuse as required by section 701(f).

`(20) A report on Indian youth mental health services as required by section 707(h).

`SEC. 802. REGULATIONS.

`(a) DEADLINES-

`(1) PROCEDURES- Not later than 90 days after the date of the enactment of the Indian Health Care Improvement Act Amendments of 2006, the Secretary shall initiate procedures under subchapter III of chapter 5 of title 5, United States Code, to negotiate and promulgate such regulations or amendments thereto that are necessary to carry out titles I, II, III, and VII and section 817. The Secretary may promulgate regulations to carry out sections 105, 115, 117, and titles IV and V, using the procedures required by chapter V of title 5, United States Code (commonly known as the `Administrative Procedure Act'). The Secretary shall issue no regulations to carry out titles VI and VIII, except as necessary to carry out section 817.

`(2) PROPOSED REGULATIONS- Proposed regulations to implement this Act shall be published in the Federal Register by the Secretary no later than 270 days after the date of the enactment of the Indian Health Care Improvement Act Amendments of 2006 and shall have no less than a 120-day comment period.

`(3) EXPIRATION OF AUTHORITY- The authority to promulgate regulations under this Act shall expire 18 months from the date of the enactment of this Act.

`(b) COMMITTEE- A negotiated rulemaking committee established pursuant to section 565 of title 5, United States Code, to carry out this section shall have as its members only representatives of the Federal Government and representatives of Indian Tribes and Tribal Organizations, a majority of whom shall be nominated by and be representatives of Indian Tribes, Tribal Organizations, and Urban Indian Organizations from each Service Area.

`(c) ADAPTATION OF PROCEDURES- The Secretary shall adapt the negotiated rulemaking procedures to the unique context of self-governance and the government-to-government relationship between the United States and Indian Tribes.

`(d) LACK OF REGULATIONS- The lack of promulgated regulations shall not limit the effect of this Act.

`(e) INCONSISTENT REGULATIONS- The provisions of this Act shall supersede any conflicting provisions of law in effect on the day before the date of the enactment of the Indian Health Care Improvement Act Amendments of 2006, and the Secretary is authorized to repeal any regulation inconsistent with the provisions of this Act.

`SEC. 803. PLAN OF IMPLEMENTATION.

`Not later than 9 months after the date of the enactment of the Indian Health Care Improvement Act Amendments of 2006, the Secretary in consultation with Indian Tribes, Tribal Organizations, and Urban Indian Organizations, shall submit to Congress a plan explaining the manner and schedule (including a schedule of appropriation requests), by title and section, by which the Secretary will implement the provisions of this Act.

`SEC. 804. AVAILABILITY OF FUNDS.

`The funds appropriated pursuant to this Act shall remain available until expended.

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

`Any limitation on the use of funds contained in an Act providing appropriations for the Department for a period with respect to the performance of abortions shall apply for that period with respect to the performance of abortions using funds contained in an Act providing appropriations for the Service.

`SEC. 806. ELIGIBILITY OF CALIFORNIA INDIANS.

`(a) IN GENERAL- The following California Indians shall be eligible for health services provided by the Service:

`(1) Any member of a federally recognized Indian Tribe.

`(2) Any descendant of an Indian who was residing in California on June 1, 1852, if such descendant--

`(A) is a member of the Indian community served by a local program of the Service; and

`(B) is regarded as an Indian by the community in which such descendant lives.

`(3) Any Indian who holds trust interests in public domain, national forest, or reservation allotments in California.

`(4) Any Indian in California who is listed on the plans for distribution of the assets of rancherias and reservations located within the State of California under the Act of August 18, 1958 (72 Stat. 619), and any descendant of such an Indian.

`(b) CLARIFICATION- Nothing in this section may be construed as expanding the eligibility of California Indians for health services provided by the Service beyond the scope of eligibility for such health services that applied on May 1, 1986.

`SEC. 807. HEALTH SERVICES FOR INELIGIBLE PERSONS.

`(a) CHILDREN- Any individual who--

`(1) has not attained 19 years of age;

`(2) is the natural or adopted child, stepchild, foster child, legal ward, or orphan of an eligible Indian; and

`(3) is not otherwise eligible for health services provided by the Service,

shall be eligible for all health services provided by the Service on the same basis and subject to the same rules that apply to eligible Indians until such individual attains 19 years of age. The existing and potential health needs of all such individuals shall be taken into consideration by the Service in determining the need for, or the allocation of, the health resources of the Service. If such an individual has been determined to be legally incompetent prior to attaining 19 years of age, such individual shall remain eligible for such services until 1 year after the date of a determination of competency.

`(b) SPOUSES- Any spouse of an eligible Indian who is not an Indian, or who is of Indian descent but not otherwise eligible for the health services provided by the Service, shall be eligible for such health services if all such spouses or spouses who are married to members of the Indian Tribe(s) being served are made eligible, as a class, by an appropriate resolution of the governing body of the Indian Tribe or Tribal Organization providing such services. The health needs of persons made eligible under this paragraph shall not be taken into consideration by the Service in determining the need for, or allocation of, its health resources.

`(c) PROVISION OF SERVICES TO OTHER INDIVIDUALS-

`(1) IN GENERAL- The Secretary is authorized to provide health services under this subsection through health programs operated directly by the Service to individuals who reside within the Service Unit and who are not otherwise eligible for such health services if--

`(A) the Indian Tribes served by such Service Unit request such provision of health services to such individuals; and

`(B) the Secretary and the served Indian Tribes have jointly determined that--

`(i) the provision of such health services will not result in a denial or diminution of health services to eligible Indians; and

`(ii) there is no reasonable alternative health facilities or services, within or without the Service Unit, available to meet the health needs of such individuals.

`(2) PROGRAMS- In the case of a Tribal Health Program, the governing body of the Indian Tribe or Tribal Organization providing health services under such Tribal Health Program is authorized to determine whether health services should be provided under its Funding Agreement to individuals who are not otherwise eligible for such services. In making such determination, the governing body shall take into account the considerations described in clauses (i) and (ii) of paragraph (1)(B).

`(3) PAYMENT FOR SERVICES-

`(A) IN GENERAL- Persons receiving health services provided by the Service under this subsection shall be liable for payment of such health services under a schedule of charges prescribed by the Secretary which, in the judgment of the Secretary, results in reimbursement in an amount not less than the actual cost of providing the health services. Notwithstanding section 404 of this Act or any other provision of law, amounts collected under this subsection, including Medicare, Medicaid, or SCHIP reimbursements under titles XVIII, XIX, and XXI of the Social Security Act, shall be credited to the account of the program providing the service and shall be used for the purposes listed in section 401(d)(2) and amounts collected under this subsection shall be available for expenditure within such program.

`(B) INDIGENT PEOPLE- Health services may be provided by the Secretary through the Service under this subsection to an indigent individual who would not be otherwise eligible for such health services but for the provisions of paragraph (1) only if an agreement has been entered into with a State or local government under which the State or local government agrees to reimburse the Service for the expenses incurred by the Service in providing such health services to such indigent individual.

`(4) REVOCATION OF CONSENT FOR SERVICES-

`(A) SINGLE TRIBE SERVICE AREA- In the case of a Service Area which serves only 1 Indian Tribe, the authority of the Secretary to provide health services under paragraph (1) shall terminate at the end of the fiscal year succeeding the fiscal year in which the governing body of the Indian Tribe revokes its concurrence to the provision of such health services.

`(B) MULTITRIBAL SERVICE AREA- In the case of a multitribal Service Area, the authority of the Secretary to provide health services under paragraph (1) shall terminate at the end of the fiscal year succeeding the fiscal year in which at least 51 percent of the number of Indian Tribes in the Service Area revoke their concurrence to the provisions of such health services.

`(d) OTHER SERVICES- The Service may provide health services under this subsection to individuals who are not eligible for health services provided by the Service under any other provision of law in order to--

`(1) achieve stability in a medical emergency;

`(2) prevent the spread of a communicable disease or otherwise deal with a public health hazard;

`(3) provide care to non-Indian women pregnant with an eligible Indian's child for the duration of the pregnancy through postpartum; or

`(4) provide care to immediate family members of an eligible individual if such care is directly related to the treatment of the eligible individual.

`(e) HOSPITAL PRIVILEGES FOR PRACTITIONERS- Hospital privileges in health facilities operated and maintained by the Service or operated under a Funding Agreement may be extended to non-Service health care practitioners who provide services to individuals described in subsection (a), (b), (c), or (d). Such non-Service health care practitioners may, as part of the privileging process, be designated as employees of the Federal Government for purposes of section 1346(b) and chapter 171 of title 28, United States Code (relating to Federal tort claims) only with respect to acts or omissions which occur in the course of providing services to eligible individuals as a part of the conditions under which such hospital privileges are extended.

`(f) ELIGIBLE INDIAN- For purposes of this section, the term `eligible Indian' means any Indian who is eligible for health services provided by the Service without regard to the provisions of this section.

`SEC. 808. REALLOCATION OF BASE RESOURCES.

`(a) REPORT REQUIRED- Notwithstanding any other provision of law, any allocation of Service funds for a fiscal year that reduces by 5 percent or more from the previous fiscal year the funding for any recurring program, project, or activity of a Service Unit may be implemented only after the Secretary has submitted to the President, for inclusion in the report required to be transmitted to Congress under section 801, a report on the proposed change in allocation of funding, including the reasons for the change and its likely effects.

`(b) EXCEPTION- Subsection (a) shall not apply if the total amount appropriated to the Service for a fiscal year is at least 5 percent less than the amount appropriated to the Service for the previous fiscal year.

`SEC. 809. RESULTS OF DEMONSTRATION PROJECTS.

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

`SEC. 810. PROVISION OF SERVICES IN MONTANA.

`(a) CONSISTENT WITH COURT DECISION- The Secretary, acting through the Service, shall provide services and benefits for Indians in Montana in a manner consistent with the decision of the United States Court of Appeals for the Ninth Circuit in McNabb v. Bowen, 829 F.2d 787 (9th Cir. 1987).

`(b) CLARIFICATION- The provisions of subsection (a) shall not be construed to be an expression of the sense of Congress on the application of the decision described in subsection (a) with respect to the provision of services or benefits for Indians living in any State other than Montana.

`SEC. 811. MORATORIUM.

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

`SEC. 812. TRIBAL EMPLOYMENT.

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

`SEC. 813. SEVERABILITY PROVISIONS.

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

`SEC. 814. APPROPRIATIONS; AVAILABILITY.

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

`SEC. 815. AUTHORIZATION OF APPROPRIATIONS.

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

(b) RATE OF PAY-

(1) POSITIONS AT LEVEL IV- Section 5315 of title 5, United States Code, is amended by striking `Assistant Secretaries of Health and Human Services (6).' and inserting `Assistant Secretaries of Health and Human Services (7).'.

(2) POSITIONS AT LEVEL V- Section 5316 of title 5, United States Code, is amended by striking `Director, Indian Health Service, Department of Health and Human Services.'.

(1) Section 3307(b)(1)(C) of the Children's Health Act of 2000 (25 U.S.C. 1671 note; Public Law 106-310) is amended by striking `Director of the Indian Health Service' and inserting `Assistant Secretary for Indian Health'.

(2) The Indian Lands Open Dump Cleanup Act of 1994 is amended--

(A) in section 3 (25 U.S.C. 3902)--

(i) by striking paragraph (2);

(ii) by redesignating paragraphs (1), (3), (4), (5), and (6) as paragraphs (4), (5), (2), (6), and (1), respectively, and moving those paragraphs so as to appear in numerical order; and

(iii) by inserting before paragraph (4) (as redesignated by clause (ii)) the following:

`(3) ASSISTANT SECRETARY- The term `Assistant Secretary' means the Assistant Secretary for Indian Health.';

(B) in section 5 (25 U.S.C. 3904), by striking the section heading and inserting the following:

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

(C) in section 6(a) (25 U.S.C. 3905(a)), in the subsection heading, by striking `DIRECTOR' and inserting `ASSISTANT SECRETARY';

(D) in section 9(a) (25 U.S.C. 3908(a)), in the subsection heading, by striking `DIRECTOR' and inserting `ASSISTANT SECRETARY'; and

(E) by striking `Director' each place it appears and inserting `Assistant Secretary'.

(3) Section 5504(d)(2) of the Augustus F. Hawkins-Robert T. Stafford Elementary and Secondary School Improvement Amendments of 1988 (25 U.S.C. 2001 note; Public Law 100-297) is amended by striking `Director of the Indian Health Service' and inserting `Assistant Secretary for Indian Health'.

(4) Section 203(a)(1) of the Rehabilitation Act of 1973 (29 U.S.C. 763(a)(1)) is amended by striking `Director of the Indian Health Service' and inserting `Assistant Secretary for Indian Health'.

(5) Subsections (b) and (e) of section 518 of the Federal Water Pollution Control Act (33 U.S.C. 1377) are amended by striking `Director of the Indian Health Service' each place it appears and inserting `Assistant Secretary for Indian Health'.

(6) Section 317M(b) of the Public Health Service Act (42 U.S.C. 247b-14(b)) is amended--

(A) by striking `Director of the Indian Health Service' each place it appears and inserting `Assistant Secretary for Indian Health'; and

(B) in paragraph (2)(A), by striking `the Directors referred to in such paragraph' and inserting `the Director of the Centers for Disease Control and Prevention and the Assistant Secretary for Indian Health'.

(7) Section 417C(b) of the Public Health Service Act (42 U.S.C. 285-9(b)) is amended by striking `Director of the Indian Health Service' and inserting `Assistant Secretary for Indian Health'.

(8) Section 1452(i) of the Safe Drinking Water Act (42 U.S.C. 300j-12(i)) is amended by striking `Director of the Indian Health Service' each place it appears and inserting `Assistant Secretary for Indian Health'.

(9) Section 803B(d)(1) of the Native American Programs Act of 1974 (42 U.S.C. 2991b-2(d)(1)) is amended in the last sentence by striking `Director of the Indian Health Service' and inserting `Assistant Secretary for Indian Health'.

(10) Section 203(b) of the Michigan Indian Land Claims Settlement Act (Public Law 105-143; 111 Stat. 2666) is amended by striking `Director of the Indian Health Service' and inserting `Assistant Secretary for Indian Health'.

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

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

(a) Medicaid-

(1) EXPANSION TO ALL COVERED SERVICES- Section 1911 of the Social Security Act (42 U.S.C. 1396j) is amended--

(A) by amending the designation and heading to read as follows:

`SEC. 1911. INDIAN HEALTH PROGRAMS.'

; and

(B) by amending subsection (a) to read as follows:

`(a) Eligibility for Payment for Medical Assistance- The Indian Health Service and an Indian Tribe, Tribal Organization, or an Urban Indian Organization shall be eligible for payment for medical assistance provided under a State plan or under waiver authority with respect to items and services furnished by the Indian Health Service, Indian Tribe, Tribal Organization, or Urban Indian Organization if the furnishing of such services meets all the conditions and requirements which are applicable generally to the furnishing of items and services under this title and under such plan or waiver authority.'.

(2) COMPLIANCE WITH CONDITIONS AND REQUIREMENTS- Subsection (b) of such section is amended to read as follows:

`(b) Compliance With Conditions and Requirements- A facility of the Indian Health Service or an Indian Tribe, Tribal Organization, or an Urban Indian Organization which is eligible for payment under subsection (a) with respect to the furnishing of items and services, but which does not meet all of the conditions and requirements of this title and under a State plan or waiver authority which are applicable generally to such facility, shall make such improvements as are necessary to achieve or maintain compliance with such conditions and requirements in accordance with a plan submitted to and accepted by the Secretary for achieving or maintaining compliance with such conditions and requirements, and shall be deemed to meet such conditions and requirements (and to be eligible for payment under this title), without regard to the extent of its actual compliance with such conditions and requirements, during the first 12 months after the month in which such plan is submitted.'.

(3) REVISION OF AUTHORITY TO ENTER INTO AGREEMENTS- Subsection (c) of such section is amended to read as follows:

`(c) Authority to Enter Into Agreements- The Secretary may enter into an agreement with a State for the purpose of reimbursing the State for medical assistance provided by the Indian Health Service, an Indian Tribe, Tribal Organization, or an Urban Indian Organization (as so defined), directly, through referral, or under contracts or other arrangements between the Indian Health Service, an Indian Tribe, Tribal Organization, or an Urban Indian Organization and another health care provider to Indians who are eligible for medical assistance under the State plan or under waiver authority.'.

(4) CROSS-REFERENCES TO SPECIAL FUND FOR IMPROVEMENT OF IHS FACILITIES; DIRECT BILLING OPTION; DEFINITIONS- Such section is further amended by striking subsection (d) and adding at the end the following new subsections:

`(d) Special Fund for Improvement of IHS Facilities- For provisions relating to the authority of the Secretary to place payments to which a facility of the Indian Health Service is eligible for payment under this title into a special fund established under section 401(c)(1) of the Indian Health Care Improvement Act, and the requirement to use amounts paid from such fund for making improvements in accordance with subsection (b), see subparagraphs (A) and (B) of section 401(c)(1) of such Act.

`(e) Direct Billing- For provisions relating to the authority of a Tribal Health Program or an Urban Indian Organization to elect to directly bill for, and receive payment for, health care items and services provided by such Program or Organization for which payment is made under this title, see section 401(d) of the Indian Health Care Improvement Act.

`(f) Definitions- In this section, the terms `Indian Health Program', `Indian Tribe', `Tribal Health Program', `Tribal Organization', and `Urban Indian Organization' have the meanings given those terms in section 4 of the Indian Health Care Improvement Act.'.

(b) Medicare-

(1) EXPANSION TO ALL COVERED SERVICES- Section 1880 of such Act (42 U.S.C. 1395qq) is amended--

(A) by amending the designation and heading to read as follows:

`SEC. 1880. INDIAN HEALTH PROGRAMS.'

; and

(B) by amending subsection (a) to read as follows:

`(a) Eligibility for Payments- Subject to subsection (e), the Indian Health Service and an Indian Tribe, Tribal Organization, or an Urban Indian Organization shall be eligible for payments under this title with respect to items and services furnished by the Indian Health Service, Indian Tribe, Tribal Organization, or Urban Indian Organization if the furnishing of such services meets all the conditions and requirements which are applicable generally to the furnishing of items and services under this title.'.

(2) COMPLIANCE WITH CONDITIONS AND REQUIREMENTS- Subsection (b) of such section is amended to read as follows:

`(b) Compliance With Conditions and Requirements- Subject to subsection (e), a facility of the Indian Health Service or an Indian Tribe, Tribal Organization, or an Urban Indian Organization which is eligible for payment under subsection (a) with respect to the furnishing of items and services, but which does not meet all of the conditions and requirements of this title which are applicable generally to such facility, shall make such improvements as are necessary to achieve or maintain compliance with such conditions and requirements in accordance with a plan submitted to and accepted by the Secretary for achieving or maintaining compliance with such conditions and requirements, and shall be deemed to meet such conditions and requirements (and to be eligible for payment under this title), without regard to the extent of its actual compliance with such conditions and requirements, during the first 12 months after the month in which such plan is submitted.'.

(3) CROSS-REFERENCES TO SPECIAL FUND FOR IMPROVEMENT OF IHS FACILITIES; DIRECT BILLING OPTION; DEFINITIONS-

(A) IN GENERAL- Such section is further amended by striking subsections (c) and (d) and inserting the following new subsections:

`(c) Special Fund for Improvement of IHS Facilities- For provisions relating to the authority of the Secretary to place payments to which a facility of the Indian Health Service is eligible for payment under this title into a special fund established under section 401(c)(1) of the Indian Health Care Improvement Act, and the requirement to use amounts paid from such fund for making improvements in accordance with subsection (b), see subparagraphs (A) and (B) of section 401(c)(1) of such Act.

`(d) Direct Billing- For provisions relating to the authority of a Tribal Health Program or an Urban Indian Organization to elect to directly bill for, and receive payment for, health care items and services provided by such Program or Organization for which payment is made under this title, see section 401(d) of the Indian Health Care Improvement Act.'.

(B) CONFORMING AMENDMENT- Paragraph (3) of section 1880(e) of such Act (42 U.S.C. 1395qq(e)) is amended by inserting `and section 401(c)(1) of the Indian Health Care Improvement Act' after `Subsection (c)'.

(4) DEFINITIONS- Such section is further amended by amending subsection (f) to read as follows:

`(f) Definitions- In this section, the terms `Indian Health Program', `Indian Tribe', `Service Unit', `Tribal Health Program', `Tribal Organization', and `Urban Indian Organization' have the meanings given those terms in section 4 of the Indian Health Care Improvement Act.'.

(1) by redesignating subparagraph (D) as subparagraph (E); and

(2) by inserting after subparagraph (C), the following new subparagraph:

`(D) Section 1911 (relating to Indian Health Programs, other than subsection (d) of such section).'.

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

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

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

`(a) Agreements With States for Medicaid and SCHIP Outreach on or Near Reservations to Increase the Enrollment of Indians in Those Programs-

`(1) IN GENERAL- In order to improve the access of Indians residing on or near a reservation to obtain benefits under the Medicaid and State children's health insurance programs established under titles XIX and XXI, the Secretary shall encourage the State to take steps to provide for enrollment on or near the reservation. Such steps may include outreach efforts such as the outstationing of eligibility workers, entering into agreements with the Indian Health Service, Indian Tribes, Tribal Organizations, and Urban Indian Organizations to provide outreach, education regarding eligibility and benefits, enrollment, and translation services when such services are appropriate.

`(2) CONSTRUCTION- Nothing in subparagraph (A) shall be construed as affecting arrangements entered into between States and the Indian Health Service, Indian Tribes, Tribal Organizations, or Urban Indian Organizations for such Service, Tribes, or Organizations to conduct administrative activities under such titles.

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

`(c) Definition of Indian Tribe; Indian Health Program; Tribal Organization; Urban Indian Organization- In this section, the terms `Indian Tribe', `Indian Health Program', `Tribal Organization', and `Urban Indian Organization' have the meanings given those terms in section 4 of the Indian Health Care Improvement Act.'.

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

(a) Nonapplication of 10 Percent Limit on Outreach and Certain Other Expenditures- Section 2105(c)(2) of the Social Security Act (42 U.S.C. 1397ee(c)(2)) is amended by adding at the end the following new subparagraph:

`(C) NONAPPLICATION TO EXPENDITURES FOR OUTREACH TO INCREASE THE ENROLLMENT OF INDIAN CHILDREN UNDER THIS TITLE AND TITLE XIX- The limitation under subparagraph (A) on expenditures for items described in subsection (a)(1)(D) shall not apply in the case of expenditures for outreach activities to families of Indian children likely to be eligible for child health assistance under the plan or medical assistance under the State plan under title XIX (or under a waiver of such plan), to inform such families of the availability of, and to assist them in enrolling their children in, such

plans, including such activities conducted under grants, contracts, or agreements entered into under section 1139(a).'.

(b) Assurance of Payments to Indian Health Care Providers for Child Health Assistance- Section 2102(b)(3)(D) of such Act (42 U.S.C. 1397bb(b)(3)(D)) is amended by striking `(as defined in section 4(c) of the Indian Health Care Improvement Act, 25 U.S.C. 1603(c))' and inserting `, including how the State will ensure that payments are made to Indian Health Programs and Urban Indian Organizations operating in the State for the provision of such assistance'.

(c) Inclusion of Other Indian Financed Health Care Programs in Exemption From Prohibition on Certain Payments- Section 2105(c)(6)(B) of such Act (42 U.S.C. 1397ee(c)(6)(B)) is amended by striking `insurance program, other than an insurance program operated or financed by the Indian Health Service' and inserting `program, other than a health care program operated or financed by the Indian Health Service or by an Indian Tribe, Tribal Organization, or Urban Indian Organization'.

(d) Satisfaction of Medicaid Documentation Requirements-

(1) IN GENERAL- Section 1903(x)(3)(B) of the Social Security Act (42 U.S.C. 1396b(x)(3)(B)) is amended--

(A) by redesignating clause (v) as clause (vi); and

(B) by inserting after clause (iv), the following new clause:

`(v)(I) Except as provided in subclause (II), a document issued by a federally-recognized Indian tribe evidencing membership or enrollment in, or affiliation with, such tribe.

`(II) With respect to those federally-recognized Indian tribes located within States having an international border whose membership includes individuals who are not citizens of the United States, the Secretary shall, after consulting with such tribes, issue regulations authorizing the presentation of such other forms of documentation (including tribal documentation, if appropriate) that the Secretary determines to be satisfactory documentary evidence of citizenship or nationality for purposes of satisfying the requirement of this subsection.'.

(2) TRANSITION RULE- During the period that begins on July 1, 2006, and ends on the effective date of final regulations issued under subclause (II) of section 1903(x)(3)(B)(v) of the Social Security Act (42 U.S.C. 1396b(x)(3)(B)(v)) (as added by paragraph (1)), an individual who is a member of a federally-recognized Indian tribe described in subclause (II) of that section who presents a document described in subclause (I) of such section that is issued by such Indian tribe, shall be deemed to have presented satisfactory evidence of citizenship or nationality for purposes of satisfying the requirement of subsection (x) of section 1903 of such Act.

(e) Definitions- Section 2110(c) of such Act (42 U.S.C. 1397jj(c)) is amended by adding at the end the following new paragraph:

`(9) INDIAN; INDIAN HEALTH PROGRAM; INDIAN TRIBE; ETC- The terms `Indian', `Indian Health Program', `Indian Tribe', `Tribal Organization', and `Urban Indian Organization' have the meanings given those terms in section 4 of the Indian Health Care Improvement Act.'.

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

(a) Premiums and Cost Sharing Protection Under Medicaid-

(1) IN GENERAL- Section 1916 of the Social Security Act (42 U.S.C. 1396o) is amended--

(A) in subsection (a), in the matter preceding paragraph (1), by striking `and (i)' and inserting `, (i), and (j)'; and

(B) by adding at the end the following new subsection:

`(j) No Premiums or Cost Sharing for Indians Furnished Items or Services Directly by Indian Health Programs or Through Referral Under the Contract Health Service-

`(1) NO COST SHARING FOR ITEMS OR SERVICES FURNISHED TO INDIANS THROUGH INDIAN HEALTH PROGRAMS-

`(A) IN GENERAL- No enrollment fee, premium, or similar charge, and no deduction, copayment, cost sharing, or similar charge shall be imposed against an Indian who is furnished an item or service directly by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization or through referral under the contract health service for which payment may be made under this title.

`(B) NO REDUCTION IN AMOUNT OF PAYMENT TO INDIAN HEALTH PROVIDERS- Payment due under this title to the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or a health care provider through referral under the contract health service for the furnishing of an item or service to an Indian who is eligible for assistance under such title, may not be reduced by the amount of any enrollment fee, premium, or similar charge, or any deduction, copayment, cost sharing, or similar charge that would be due from the Indian but for the operation of subparagraph (A).

`(2) RULE OF CONSTRUCTION- Nothing in this subsection shall be construed as restricting the application of any other limitations on the imposition of premiums or cost sharing that may apply to an individual receiving medical assistance under this title who is an Indian.

`(3) DEFINITIONS- In this subsection, the terms `contract health service', `Indian', `Indian Tribe', `Tribal Organization', and `Urban Indian Organization' have the meanings given those terms in section 4 of the Indian Health Care Improvement Act.'.

(2) CONFORMING AMENDMENT- Section 1916A(a)(1) of such Act (42 U.S.C. 1396o-1(a)(1)) is amended by striking `section 1916(g)' and inserting `subsections (g), (i), or (j) of section 1916'.

(b) Treatment of Certain Property for Medicaid and SCHIP Eligibility-

(1) MEDICAID- Section 1902(e) of the Social Security Act (42 U.S.C. 1396a) is amended by adding at the end the following new paragraph:

`(13) Notwithstanding any other requirement of this title or any other provision of Federal or State law, a State shall disregard the following property for purposes of determining eligibility for medical assistance under this title:

`(A) Property, including real property and improvements, located on a reservation, including any federally recognized Indian Tribe's reservation, pueblo, or colony, including former reservations in Oklahoma, Alaska Native regions established by the Alaska Native Claims Settlement Act, and Indian allotments on or near a reservation as designated and approved by the Bureau of Indian Affairs of the Department of the Interior.

`(B) For any federally recognized Tribe not described in subparagraph (A), property located within the most recent boundaries of a prior Federal reservation.

`(C) Ownership interests in rents, leases, royalties, or usage rights related to natural resources (including extraction of natural resources or harvesting of timber, other plants and plant products, animals, fish, and shellfish) resulting from the exercise of federally protected rights.

`(D) Ownership interests in or usage rights to items not covered by subparagraphs (A) through (C) that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable tribal law or custom.'.

(2) APPLICATION TO SCHIP- Section 2107(e)(1) of such Act (42 U.S.C. 1397gg(e)(1)), as amended by section 201(c), is amended--

(A) by redesignating subparagraphs (B) through (E), as subparagraphs (C) through (F), respectively; and

(B) by inserting after subparagraph (A), the following new subparagraph:

`(B) Section 1902(e)(13) (relating to disregard of certain property for purposes of making eligibility determinations).'.

(c) Continuation of Current Law Protections of Certain Indian Property From Medicaid Estate Recovery- Section 1917(b)(3) of the Social Security Act (42 U.S.C. 1396p(b)(3)) is amended--

(1) by inserting `(A)' after `(3)'; and

(2) by adding at the end the following new subparagraph:

`(B) The standards specified by the Secretary under subparagraph (A) shall require that the procedures established by the State agency under subparagraph (A) exempt income, resources, and property that are exempt from the application of this subsection as of April 1, 2003, under manual instructions issued to carry out this subsection (as in effect on such date) because of the Federal responsibility for Indian Tribes and Alaska Native Villages. Nothing in this subparagraph shall be construed as preventing the Secretary from providing additional estate recovery exemptions under this title for Indians.'.

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

Section 1139 of the Social Security Act (42 U.S.C. 1320b-9), as amended by section 202, is amended by redesignating subsection (c) as subsection (d), and inserting after subsection (b) the following new subsection:

`(c) Nondiscrimination in Qualifications for Payment for Services Under Federal Health Care Programs-

`(1) REQUIREMENT TO SATISFY GENERALLY APPLICABLE PARTICIPATION REQUIREMENTS-

`(A) IN GENERAL- A Federal health care program must accept an entity that is operated by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization as a provider eligible to receive payment under the program for health care services furnished to an Indian on the same basis as any other provider qualified to participate as a provider of health care services under the program if the entity meets generally applicable State or other requirements for participation as a provider of health care services under the program.

`(B) SATISFACTION OF STATE OR LOCAL LICENSING OR RECOGNITION REQUIREMENTS- Any requirement for participation as a provider of health care services under a Federal health care program that an entity be licensed or recognized under the State or local law where the entity is located to furnish health care services shall be deemed to have been met in the case of an entity operated by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization if the entity meets all the applicable standards for such licensing or recognition, regardless of whether the entity obtains a license or other documentation under such State or local law. In accordance with section 221 of the Indian Health Care Improvement Act, the absence of the licensing of a health care professional employed by such an entity under the State or local law where the entity is located shall not be taken into account for purposes of determining whether the entity meets such standards, if the professional is licensed in another State.

`(2) PROHIBITION ON FEDERAL PAYMENTS TO ENTITIES OR INDIVIDUALS EXCLUDED FROM PARTICIPATION IN FEDERAL HEALTH CARE PROGRAMS OR WHOSE STATE LICENSES ARE UNDER SUSPENSION OR HAVE BEEN REVOKED-

`(A) EXCLUDED ENTITIES- No entity operated by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization that has been excluded from participation in any Federal health care program or for which a license is suspended or has been revoked by the State where the entity is located shall be eligible to receive payment under any such program for health care services furnished to an Indian.

`(B) EXCLUDED INDIVIDUALS- No individual who has been excluded from participation in any Federal health care program or whose State license is suspended or has been revoked shall be eligible to receive payment under any such program for health care services furnished by that individual, directly or through an entity that is otherwise eligible to receive payment for health care services, to an Indian.

`(C) FEDERAL HEALTH CARE PROGRAM DEFINED- In this subsection, the term, `Federal health care program' has the meaning given that term in section 1128B(f), except that, for purposes of this subsection, such term shall include the health insurance program under chapter 89 of title 5, United States Code.'.

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

(a) In General- Section 1139 of the Social Security Act (42 U.S.C. 1320b-9), as amended by sections 202 and 205, is amended by redesignating subsection (d) as subsection (e), and inserting after subsection (c) the following new subsection:

`(d) Consultation With Tribal Technical Advisory Group- The Secretary shall maintain within the Centers for Medicaid and Medicare Services a Tribal Technical Advisory Group, established in accordance with requirements of the charter dated September 30, 2003, and in such group shall include a representative of the Urban Indian Organizations and the Service. The representative of the Urban Indian Organization shall be deemed to be an elected officer of a tribal government for purposes of applying section 204(b) of the Unfunded Mandates Reform Act of 1995 (2 U.S.C. 1534(b)).'.

(b) Solicitation of Advice Under Medicaid and SCHIP-

(1) MEDICAID STATE PLAN AMENDMENT- Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)) is amended--

(A) in paragraph (69), by striking `and' at the end;

(B) in paragraph (70)(B)(iv), by striking the period at the end and inserting `; and'; and

`(71) in the case of any State in which the Indian Health Service operates or funds health care programs, or in which 1 or more Indian Health Programs or Urban Indian Organizations (as such terms are defined in section 4 of the Indian Health Care Improvement Act) provide health care in the State for which medical assistance is available under such title, provide for a process under which the State seeks advice on a regular, ongoing basis from designees of such Indian Health Programs and Urban Indian Organizations on matters relating to the application of this title that are likely to have a direct effect on such Indian Health Programs and Urban Indian Organizations and that--

`(A) shall include solicitation of advice prior to submission of any plan amendments, waiver requests, and proposals for demonstration projects likely to have a direct effect on Indians, Indian Health Programs, or Urban Indian Organizations; and

`(B) may include appointment of an advisory committee and of a designee of such Indian Health Programs and Urban Indian Organizations to the medical care advisory committee advising the State on its State plan under this title.'.

(2) APPLICATION TO SCHIP- Section 2107(e)(1) of such Act (42 U.S.C. 1397gg(e)(1)), as amended by sections 201(c) and 204(b)(2), is amended--

(A) by redesignating subparagraphs (B) through (F) as subparagraphs (C) through (G), respectively; and

(B) by inserting after subparagraph (A), the following new subparagraph:

`(B) Section 1902(a)(71) (relating to the option of certain States to seek advice from designees of Indian Health Programs and Urban Indian Organizations).'.

(c) Rule of Construction- Nothing in the amendments made by this section shall be construed as superseding existing advisory committees, working groups, guidance, or other advisory procedures established by the Secretary of Health and Human Services or by any State with respect to the provision of health care to Indians.

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

(a) Exclusion Waiver Authority- Section 1128 of the Social Security Act (42 U.S.C. 1320a-7) is amended by adding at the end the following new subsection:

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

(b) Certain Transactions Involving Indian Health Care Programs Deemed to Be in Safe Harbors- Section 1128B(b) of the Social Security Act (42 U.S.C. 1320a-7b(b)) is amended by adding at the end the following new paragraph:

`(4) RENUMERATION- Subject to such conditions as the Secretary may promulgate from time to time as necessary to prevent fraud and abuse, for purposes of paragraphs (1) and (2) and section 1128A(a), the following transfers shall not be treated as remuneration:

`(A) TRANSFERS BETWEEN INDIAN HEALTH PROGRAMS, INDIAN TRIBES, TRIBAL ORGANIZATIONS, AND URBAN INDIAN ORGANIZATIONS- Transfers of anything of value between or among an Indian Health Program, Indian Tribe, Tribal Organization, or Urban Indian Organization, that are made for the purpose of providing necessary health care items and services to any patient served by such Program, Tribe, or Organization and that consist of--

`(i) services in connection with the collection, transport, analysis, or interpretation of diagnostic specimens or test data;

`(ii) inventory or supplies;

`(iii) staff; or

`(iv) a waiver of all or part of premiums or cost sharing.

`(B) TRANSFERS BETWEEN INDIAN HEALTH PROGRAMS, INDIAN TRIBES, TRIBAL ORGANIZATIONS, OR URBAN INDIAN ORGANIZATIONS AND PATIENTS- Transfers of anything of value between an Indian Health Program, Indian Tribe, Tribal Organization, or Urban Indian Organization and any patient served or eligible for service from an Indian Health Program, Indian Tribe, Tribal Organization, or Urban Indian Organization, including any patient served or eligible for service pursuant to section 807 of the Indian Health Care Improvement Act, but only if such transfers--

`(i) consist of expenditures related to providing transportation for the patient for the provision of necessary health care items or services, provided that the provision of such transportation is not advertised, nor an incentive of which the value is disproportionately large in relationship to the value of the health care item or service (with respect to the value of the item or service itself or, for preventative items or services, the future health care costs reasonably expected to be avoided);

`(ii) consist of expenditures related to providing housing to the patient (including a pregnant patient) and immediate family members or an escort necessary to assuring the timely provision of health care items and services to the patient, provided that the provision of such housing is not advertised nor an incentive of which the value is disproportionately large in relationship to the value of the health care item or service (with respect to the value of the item or service itself or, for preventative items or services, the future health care costs reasonably expected to be avoided); or

`(iii) are for the purpose of paying premiums or cost sharing on behalf of such a patient, provided that the making of such payment is not subject to conditions other than conditions agreed to under a contract for the delivery of contract health services.

`(C) CONTRACT HEALTH SERVICES- A transfer of anything of value negotiated as part of a contract entered into between an Indian Health Program, Indian Tribe, Tribal Organization, Urban Indian Organization, or the Indian Health Service and a contract care provider for the delivery of contract health services authorized by the Indian Health Service, provided that--

`(i) such a transfer is not tied to volume or value of referrals or other business generated by the parties; and

`(ii) any such transfer is limited to the fair market value of the health care items or services provided or, in the case of a transfer of items or services related to preventative care, the value of the future health care costs reasonably expected to be avoided.

`(D) OTHER TRANSFERS- Any other transfer of anything of value involving an Indian Health Program, Indian Tribe, Tribal Organization, or Urban Indian Organization, or a patient served or eligible for service from an Indian Health Program, Indian Tribe, Tribal Organization, or Urban Indian Organization, that the Secretary, in consultation with the Attorney General, determines is appropriate, taking into account the special circumstances of such Indian Health Programs, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, and of patients served by such Programs, Tribes, and Organizations.'.

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

(a) In General- Section 1932 of the Social Security Act (42 U.S.C. 1396u-2) is amended by adding at the end the following new subsection:

`(h) Special Rules With Respect to Indian Enrollees, Indian Health Care Providers, and Indian Managed Care Entities-

`(1) ENROLLEE OPTION TO SELECT AN INDIAN HEALTH CARE PROVIDER AS PRIMARY CARE PROVIDER- In the case of a non-Indian Medicaid managed care entity that--

`(A) has an Indian enrolled with the entity; and

`(B) has an Indian health care provider that is participating as a primary care provider within the network of the entity,

insofar as the Indian is otherwise eligible to receive services from such Indian health care provider and the Indian health care provider has the capacity to provide primary care services to such Indian, the contract with the entity under section 1903(m) or under section 1905(t)(3) shall require, as a condition of receiving payment under such contract, that the Indian shall be allowed to choose such Indian health care provider as the Indian's primary care provider under the entity.

`(2) ASSURANCE OF PAYMENT TO INDIAN HEALTH CARE PROVIDERS FOR PROVISION OF COVERED SERVICES- Each contract with a managed care entity under section 1903(m) or under section 1905(t)(3) shall require any such entity that has a significant percentage of Indian enrollees (as determined by the Secretary), as a condition of receiving payment under such contract to satisfy the following requirements:

`(A) DEMONSTRATION OF PARTICIPATING INDIAN HEALTH CARE PROVIDERS OR APPLICATION OF ALTERNATIVE PAYMENT ARRANGEMENTS- Subject to subparagraph (E), to--

`(i) demonstrate that the number of Indian health care providers that are participating providers with respect to such entity are sufficient to ensure timely access to covered Medicaid managed care services for those enrollees who are eligible to receive services from such providers; or

`(ii) agree to pay Indian health care providers who are not participating providers with the entity for covered Medicaid managed care services provided to those enrollees who are eligible to receive services from such providers at a rate equal to the rate negotiated between such entity and the provider involved or, if such a rate has not been negotiated, at a rate that is not less than the level and amount of payment which the entity would make for the services if the services were furnished by a participating provider which is not an Indian health care provider.

`(B) PROMPT PAYMENT- To agree to make prompt payment (in accordance with rules applicable to managed care entities) to Indian health care providers that are participating providers with respect to such entity or, in the case of an entity to which subparagraph (A)(ii) or (E) applies, that the entity is required to pay in accordance with that subparagraph.

`(C) SATISFACTION OF CLAIM REQUIREMENT- To deem any requirement for the submission of a claim or other documentation for services covered under subparagraph (A) by the enrollee to be satisfied through the submission of a claim or other documentation by an Indian health care provider that is consistent with section 403(h) of the Indian Health Care Improvement Act.

`(D) COMPLIANCE WITH GENERALLY APPLICABLE REQUIREMENTS-

`(i) IN GENERAL- Subject to clause (ii), as a condition of payment under subparagraph (A), an Indian health care provider shall comply with the generally applicable requirements of this title, the State plan, and such entity with respect to covered Medicaid managed care services provided by the Indian health care provider to the same extent that non-Indian providers participating with the entity must comply with such requirements.

`(ii) LIMITATIONS ON COMPLIANCE WITH MANAGED CARE ENTITY GENERALLY APPLICABLE REQUIREMENTS- An Indian health care provider--

`(I) shall not be required to comply with a generally applicable requirement of a managed care entity described in clause (i) as a condition of payment under subparagraph (A) if such compliance would conflict with any other statutory or regulatory requirements applicable to the Indian health care provider; and

`(II) shall only need to comply with those generally applicable requirements of a managed care entity described in clause (i) as a condition of payment under subparagraph (A) that are necessary for the entity's compliance with the State plan, such as those related to care management, quality assurance, and utilization management.

`(E) APPLICATION OF SPECIAL PAYMENT REQUIREMENTS FOR FEDERALLY-QUALIFIED HEALTH CENTERS AND ENCOUNTER RATE FOR SERVICES PROVIDED BY CERTAIN INDIAN HEALTH CARE PROVIDERS-

`(i) FEDERALLY-QUALIFIED HEALTH CENTERS-

`(I) MANAGED CARE ENTITY PAYMENT REQUIREMENT- To agree to pay any Indian health care provider that is a Federally-qualified health center but not a participating provider with respect to the entity, for the provision of covered Medicaid managed care services by such provider to an Indian enrollee of the entity at a rate equal to the amount of payment that the entity would pay a Federally-qualified health center that is a participating provider with respect to the entity but is not an Indian health care provider for such services.

`(II) CONTINUED APPLICATION OF STATE REQUIREMENT TO MAKE SUPPLEMENTAL PAYMENT- Nothing in subclause (I) or subparagraph (A) or (B) shall be construed as waiving the application of section 1902(bb)(5) regarding the State plan requirement to make any supplemental payment due under such section to a Federally-qualified health center for services furnished by such center to an enrollee of a managed care entity (regardless of whether the Federally-qualified health center is or is not a participating provider with the entity).

`(ii) CONTINUED APPLICATION OF ENCOUNTER RATE FOR SERVICES PROVIDED BY CERTAIN INDIAN HEALTH CARE PROVIDERS- If the amount paid by a managed care entity to an Indian health care provider that is not a Federally-qualified health center and that has elected to receive payment under this title as an Indian Health Service provider under the July 11, 1996, Memorandum of Agreement between the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) and the Indian Health Service for services provided by such provider to an Indian enrollee with the managed care entity is less than the encounter rate that applies to the provision of such services under such memorandum, the State plan shall provide for payment to the Indian health care provider of the difference between the applicable encounter rate under such memorandum and the amount paid by the managed care entity to the provider for such services.

`(F) CONSTRUCTION- Nothing in this paragraph shall be construed as waiving the application of section 1902(a)(30)(A) (relating to application of standards to assure that payments are consistent with efficiency, economy, and quality of care).

`(3) OFFERING OF MANAGED CARE THROUGH INDIAN MEDICAID MANAGED CARE ENTITIES- If--

`(A) a State elects to provide services through Medicaid managed care entities under its Medicaid managed care program; and

`(B) an Indian health care provider that is funded in whole or in part by the Indian Health Service, or a consortium composed of 1 or more Tribes, Tribal Organizations, or Urban Indian Organizations, and which also may include the Indian Health Service, has established an Indian Medicaid managed care entity in the State that meets generally applicable standards required of such an entity under such Medicaid managed care program,

the State shall offer to enter into an agreement with the entity to serve as a Medicaid managed care entity with respect to eligible Indians served by such entity under such program.

`(4) SPECIAL RULES FOR INDIAN MANAGED CARE ENTITIES- The following are special rules regarding the application of a Medicaid managed care program to Indian Medicaid managed care entities:

`(A) ENROLLMENT-

`(i) LIMITATION TO INDIANS- An Indian Medicaid managed care entity may restrict enrollment under such program to Indians and to members of specific Tribes in the same manner as Indian Health Programs may restrict the delivery of services to such Indians and tribal members.

`(ii) NO LESS CHOICE OF PLANS- Under such program the State may not limit the choice of an Indian among Medicaid managed care entities only to Indian Medicaid managed care entities or to be more restrictive than the choice of managed care entities offered to individuals who are not Indians.

`(iii) DEFAULT ENROLLMENT-

`(I) IN GENERAL- If such program of a State requires the enrollment of Indians in a Medicaid managed care entity in order to receive benefits, the State, taking into consideration the criteria specified in subsection (a)(4)(D)(ii)(I), shall provide for the enrollment of Indians described in subclause (II) who are not otherwise enrolled with such an entity in an Indian Medicaid managed care entity described in such clause.

`(II) INDIAN DESCRIBED- An Indian described in this subclause, with respect to an Indian Medicaid managed care entity, is an Indian who, based upon the service area and capacity of the entity, is eligible to be enrolled with the entity consistent with subparagraph (A).

`(iv) EXCEPTION TO STATE LOCK-IN- A request by an Indian who is enrolled under such program with a non-Indian Medicaid managed care entity to change enrollment with that entity to enrollment with an Indian Medicaid managed care entity shall be considered cause for granting such request under procedures specified by the Secretary.

`(B) FLEXIBILITY IN APPLICATION OF SOLVENCY- In applying section 1903(m)(1) to an Indian Medicaid managed care entity--

`(i) any reference to a `State' in subparagraph (A)(ii) of that section shall be deemed to be a reference to the `Secretary'; and

`(ii) the entity shall be deemed to be a public entity described in subparagraph (C)(ii) of that section.

`(C) EXCEPTIONS TO ADVANCE DIRECTIVES- The Secretary may modify or waive the requirements of section 1902(w) (relating to provision of written materials on advance directives) insofar as the Secretary finds that the requirements otherwise imposed are not an appropriate or effective way of communicating the information to Indians.

`(D) FLEXIBILITY IN INFORMATION AND MARKETING-

`(i) MATERIALS- The Secretary may modify requirements under subsection (a)(5) to ensure that information described in that subsection is provided to enrollees and potential enrollees of Indian Medicaid managed care entities in a culturally appropriate and understandable manner that clearly communicates to such enrollees and potential enrollees their rights, protections, and benefits.

`(ii) DISTRIBUTION OF MARKETING MATERIALS- The provisions of subsection (d)(2)(B) requiring the distribution of marketing materials to an entire service area shall be deemed satisfied in the case of an Indian Medicaid managed care entity that distributes appropriate materials only to those Indians who are potentially eligible to enroll with the entity in the service area.

`(5) MALPRACTICE INSURANCE- Insofar as, under a Medicaid managed care program, a health care provider is required to have medical malpractice insurance coverage as a condition of contracting as a provider with a Medicaid managed care entity, an Indian health care provider that is--

`(A) a Federally-qualified health center that is covered under the Federal Tort Claims Act (28 U.S.C. 1346(b), 2671 et seq.);

`(B) providing health care services pursuant to a contract or compact under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) that are covered under the Federal Tort Claims Act (28 U.S.C. 1346(b), 2671 et seq.); or

`(C) the Indian Health Service providing health care services that are covered under the Federal Tort Claims Act (28 U.S.C. 1346(b), 2671 et seq.);

are deemed to satisfy such requirement.

`(6) DEFINITIONS- For purposes of this subsection:

`(A) INDIAN HEALTH CARE PROVIDER- The term `Indian health care provider' means an Indian Health Program or an Urban Indian Organization.

`(B) INDIAN; INDIAN HEALTH PROGRAM; SERVICE; TRIBE, TRIBAL ORGANIZATION; URBAN INDIAN ORGANIZATION- The terms `Indian', `Indian Health Program', `Service', `Tribe', `Tribal Organization', `Urban Indian Organization' have the meanings given such terms in section 4 of the Indian Health Care Improvement Act.

`(C) INDIAN MEDICAID MANAGED CARE ENTITY- The term `Indian Medicaid managed care entity' means a managed care entity that is controlled (within the meaning of the last sentence of section 1903(m)(1)(C)) by the Indian Health Service, a Tribe, Tribal Organization, or Urban Indian Organization, or a consortium, which may be composed of 1 or more Tribes, Tribal Organizations, or Urban Indian Organizations, and which also may include the Service.

`(D) NON-INDIAN MEDICAID MANAGED CARE ENTITY- The term `non-Indian Medicaid managed care entity' means a managed care entity that is not an Indian Medicaid managed care entity.

`(E) COVERED MEDICAID MANAGED CARE SERVICES- The term `covered Medicaid managed care services' means, with respect to an individual enrolled with a managed care entity, items and services that are within the scope of items and services for which benefits are available with respect to the individual under the contract between the entity and the State involved.

`(F) MEDICAID MANAGED CARE PROGRAM- The term `Medicaid managed care program' means a program under sections 1903(m) and 1932 and includes a managed care program operating under a waiver under section 1915(b) or 1115 or otherwise.'.

(b) Application to SCHIP- Section 2107(e)(1) of such Act (42 U.S.C. 1397gg(1)), as amended by sections 201(c), 204(b)(2), and 206(b)(2), is amended by adding at the end the following new subparagraph:

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

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

Section 1139 of the Social Security Act (42 U.S.C. 1320b-9), as amended by the sections 202, 205, and 206, is amended by redesignating subsection (e) as subsection (f), and inserting after subsection (d) the following new subsection:

`(e) Annual Report on Indians Served by Health Benefit Programs Funded Under This Act- Beginning January 1, 2007, and annually thereafter, the Secretary, acting through the Administrator of the Centers for Medicare and Medicaid Services and the Director of the Indian Health Service, shall submit a report to Congress regarding the enrollment and health status of Indians receiving items or services under health benefit programs funded under this Act during the preceding year. Each such report shall include the following:

`(1) The total number of Indians enrolled in, or receiving items or services under, such programs, disaggregated with respect to each such program.

`(2) The number of Indians described in paragraph (1) that also received health benefits under programs funded by the Indian Health Service.

`(3) General information regarding the health status of the Indians described in paragraph (1), disaggregated with respect to specific diseases or conditions and presented in a manner that is consistent with protections for privacy of individually identifiable health information under section 264(c) of the Health Insurance Portability and Accountability Act of 1996.

`(4) A detailed statement of the status of facilities of the Indian Health Service or an Indian Tribe, Tribal Organization, or an Urban Indian Organization with respect to such facilities' compliance with the applicable conditions and requirements of titles XVIII, XIX, and XXI, and, in the case of title XIX or XXI, under a State plan under such title or under waiver authority, and of the progress being made by such facilities (under plans submitted under sections 1880(b), 1911(b) or otherwise) toward the achievement and maintenance of such compliance.

`(5) Such other information as the Secretary determines is appropriate.'.

PURPOSE OF THE BILL

The purpose of H.R. 5312 is to amend the Indian Health Care Improvement Act to revise and extend that Act.

BACKGROUND AND NEED FOR LEGISLATION

The Indian Health Care Improvement Act (IHCIA) became Public Law 94-437 in the 94th Congress (1976), and was subsequently amended seven times. IHCIA provides health care to over two million American Indians and Alaska Natives. Congress enacted a one-year reauthorization of appropriations for IHCIA through fiscal year (FY) 2001 but efforts at further extensions were interrupted due to 9/11 events. Appropriations for Indian health have continued through appropriations for the Snyder Act, a permanent law authorizing expenditures of funds for a variety of Indian programs, including health. For FY 2006, Congress appropriated just over $3 billion to help provide health care services to American Indians and Alaska Natives.

In 1998, the Indian Health Service (IHS) of the Department of Health and Human Services started the IHCIA reauthorization process under the IHS's Tribal Consultation Policy by convening a roundtable. Coordinators from the 12 IHS areas formed working groups to examine various areas of existing law. These meetings were to inform the tribal representatives about the reauthorization process, and provide opportunities to discuss and reach consensus on recommendations for IHCIA amendments. Four regional meetings were held to provide further opportunities for tribes to provide input, share recommendations from the 12 IHS areas, and build consensus among participants for a unified position.

The IHS Director also convened a National Steering Committee (NSC) to be responsible for drafting the report on the IHCIA recommendations. The NSC is composed of one elected and one alternative tribal representative from each of the 12 IHS areas, a representative from the National Indian Health Board, the National Council of Urban Indian Health, and the Self-Governance Advisory Committee. During the course of the four meetings, this group's responsibility evolved from compiling a final report of recommendations 1

[Footnote] to the drafting of the actual IHCIA reauthorization bill language.

[Footnote 1: The final report, entitled `Speaking with One Voice,' identified areas of consensus and differences.]

H.R. 5312 is the result of the NSC Committee's work. Both the NSC and the Committee on Resources worked carefully to ensure that whenever possible, H.R. 5312 did not represent a regression from the authorities provided in current law. In addition, while changes to the Medicare system as it related to Indian health care had been proposed, the bill as reported has no changes because of concern that any changes so soon after the enactment of the Medicare Modernization Act (Public Law 108-173) may be burdensome.

As follows is a discussion of several notable sections of the reported bill.

Section 3 and Section 104. Definitions; Indian health professions scholarships

Sections 3 and 104 of the legislation, as amended, references the practice of marriage and family therapy. Practitioners of this therapy focus on the general mental and emotional health of families and couples. Congress, in the past two years, has shown an increased focus and concern regarding improving the mental health of both parents and children living on tribal lands across the country. Marriage and family therapists are one way to achieve this goal, and the bill supports scholarships for students who desire to practice in this area under the Indian Health Service (IHS).

The Committee supports the existing process by which the IHS works with limited funds to provide the scholarships under to those students pursuing degrees in the fields that the Service determines to be the most relevant. Still, given the clear statutory language of 25 U.S.C. 1603 regarding health professions, the Committee is hopeful that all professions listed will receive equal consideration for students who will eventually work within the IHS system. Should the support come from Indian Country, including the National Steering Committee, for increased focus on the services offered by marriage and family therapists, then the Committee would be supportive of more scholarship monies being made available, as the needs of tribes evolve within the urban Indian health clinics and other IHS or tribal programs.

Section 121. Community Health Aide Program for Alaska

Section 121, subject to the availability of new funding, authorizes IHS to expand the existing community health aide program nationally. The Committee considered various options prior to amending this section. The reported text will continue to allow the Community Health Aide Program (CHAP), except for Dental Health Aide Therapists' certification, to expand nationally. The dental health aide therapist program will be limited to Alaska only, and the therapists' scope of practice will be limited to the procedures as stated in the January 31, 2005, Community Health Aide Program Certification Board's Standards and Procedures. The Committee believes the importance of the dental health aide program as part of a comprehensive oral health care delivery system led by licensed dentists should not be understated. This program provides an important extension of the community health aide program because dental health aides will work and live in the villages, helping to establish disease prevention and health education programs that can break the dental disease cycle affecting many American Indians and Alaska Natives. With the emphasis on prevention, the amount of new active disease can be reduced and treatment of any new active disease can be more easily managed.

The Committee crafted the language with input from other concerned Members, after consideration of the endorsement of the dental health aide therapist program by national Indian organizations and public health organizations, and with the assistance of the American Dental Association, to ensure safety and continued quality care in the larger CHAP program by imposing certain limitations on the practice of dental health aide therapists found in paragraph (b)(7). To help ensure the continued quality of the dental health aides certified by the Federal CHAP Certification Board in Alaska, the board should include at least one dentist from outside the tribal community who has actively practiced dentistry and who has expertise in setting quality standards for evaluating competence in education and practice. In paragraph (b)(7), `medical

emergency' is defined as an injury or illness, including infection, that poses an immediate threat to a person's well being, health or life. Also in paragraph (b)(7), deciduous teeth are defined as primary teeth and adult teeth are defined as permanent teeth. The amended provision also provides for the Secretary of Health and Human Services to establish a neutral panel to conduct a study of the dental health aide therapist services and the services of other mid-level providers, such as the Community Dental Health Coordinator, as developed by the American Dental Association.

Section 512. Treatment of certain demonstration projects

In H.R. 5312 as introduced, Section 512 would make the Oklahoma City Clinic and Tulsa Clinic demonstration projects subject to the provisions of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.). The reported text will allow the clinics the continued authority to manage their specific health care delivery programs. There was concern expressed among the clinics, including statements reflected in dozens of letters received by the Committee, that the current framework of administration by the clinics was most beneficial to service the over 33,000 patients that visit the two cities from all over the State of Oklahoma. Further support of the provision in the reported text is evidenced in the letter sent by four members of the Oklahoma Congressional delegation appended to this report.

Title VII--Behavioral health programs

When the Committee references behavioral, community, or home-based mental health services for children or youth in Sections 70l(c)(1), 707(c)(2)(E), and 709(c)(3) of the bill, the Committee also intends that systems of care programs are appropriate. Systems of care employs family-centered, community based, culturally appropriate and collaborative approaches to mental health services. This is an approach that is being widely used by the Substance Abuse and Mental Health Services Administration (SAMHSA) in coordination with the IHS and other agencies, and over 30 tribal communities have implemented the systems of care approach in developing a child mental health system. SAMHSA has documented the benefit of the system of care for children's mental health services, including its application in tribal communities. The Committee encourages the use by IHS and tribes of the systems of care for children and youth mental health services.

Title IV--Access to health services

These provisions are a reflection of language that was negotiated with the Senate Finance Committee in June of 2006 and is also contained in S. 3524, as ordered reported by that Committee.

The Committee would also like to note that the introduced version of H.R. 5312 in the 108th Congress, H.R. 2440, included a section regarding the review of Medicare and Medicaid Payment system. At the request of the Department of Health and Human Services, the Committee omitted a provision requiring the Secretary of Health and Human Services to examine the extent to which Medicare and Medicaid payment methodologies take into account the unique and special circumstances of the provision of covered services by health programs operated by the relevant Service and tribal entities.

The Department indicated to the Committee that it has sufficient authority under existing law to undertake this payment methodology review. Therefore, the Committee expects the Secretary will perform such a review pursuant to existing authority. The review should include the current payment methodologies applicable to the Indian health system. The objectives of the review should be to determine the sufficiency of payments to the providers in the Indian health system under various payment methodologies both in terms of assuring access to care and payment at rates consistent with those for most favored providers. The Committee looks forward to the recommendations made by the Department of Health and Human Services to Congress.

While this study is being performed and during the time Congress reviews the Secretary's recommendations for potential legislative action, the Committee expects the Department to maintain in place the current payment methodology for Indian health programs.

COMMITTEE ACTION

H.R. 5312 was introduced on May 9, 2006, by Congressman Don Young (R-AK). The bill was referred primarily to the Committee on Resources, and additionally to the Committee on Energy and Commerce and the Committee on Ways and Means. On June 21, 2006, the Full Resources Committee met to consider the bill. Chairman Richard Pombo (R-CA) offered an amendment in the nature of a substitute to make numerous technical changes to the bill, which included removal of various new authorization levels that were not included in the version of this legislation ordered reported by the Committee on Resources in 2004, such as Section 708 of H.R. 5312, as introduced. Congressman Don Young (R-AK) offered an amendment to amendment in the nature of a substitute reflecting agreement on language pertaining to Section 121. The amendment was adopted by unanimous consent. The amendment in the nature of a substitute, as amended, was adopted by unanimous consent. The bill, as amended, was then ordered favorably reported to the House of Representatives by unanimous consent.

COMMITTEE OVERSIGHT FINDINGS AND RECOMMENDATIONS

Regarding clause 2(b)(1) of rule X and clause 3(c)(1) of rule XIII of the Rules of the House of Representatives, the Committee on Resources' oversight findings and recommendations are reflected in the body of this report.

FEDERAL ADVISORY COMMITTEE STATEMENT

The functions of the proposed advisory committee authorized in the bill are not currently being nor could they be performed by one or more agencies, an advisory committee already in existence or by enlarging the mandate of an existing advisory committee.

CONSTITUTIONAL AUTHORITY STATEMENT

Article I, section 8, section 3 of the Constitution of the United States grants Congress the authority to enact this bill.

COMPLIANCE WITH HOUSE RULE XIII

1. Cost of Legislation. Clause 3(d)(2) of rule XIII of the Rules of the House of Representatives requires an estimate and a comparison by the Committee of the costs which would be incurred in carrying out this bill. However, clause 3(d)(3)(B) of that rule provides that this requirement does not apply when the Committee has included in its report a timely submitted cost estimate of the bill prepared by the Director of the Congressional Budget Office under section 402 of the Congressional Budget Act of 1974.

2. Congressional Budget Act. As required by clause 3(c)(2) of rule XIII of the Rules of the House of Representatives and section 308(a) of the Congressional Budget Act of 1974, this bill does not contain any new budget authority, credit authority, or an increase or decrease in revenues or tax expenditures. According to the Congressional Budget Office, enactment of H.R. 5312 would increase direct spending by $8 million in 2007, by $67 million over the 2007-2011 period, and by $163 million over the 2007-2016 time frame.

3. General Performance Goals and Objectives. As required by clause 3(c)(4) of rule XIII, the general performance goal or objective of this bill is to amend the Indian Health Care Improvement Act to revise and extend that Act.

4. Congressional Budget Office Cost Estimate. Under clause 3(c)(3) of rule XIII of the Rules of the House of Representatives and section 403 of the Congressional Budget Act of 1974, the Committee has received the following cost estimate for this bill from the Director of the Congressional Budget Office:

H.R. 5312--Indian Health Care Improvement Act Amendments of 2006

Summary: H.R. 5312 would authorize the appropriation of such sums as are necessary through 2015 for the Indian Health Care Improvement Act, the primary authorizing legislation for the Indian Health Service (IHS). The bill also contains provisions that would affect direct spending, primarily in the Medicaid program.

CBO estimates that implementing H.R. 5312 would cost $2.6 billion in 2007 and $30.4 billion over the 2007-2016 period, assuming appropriation of the necessary amounts. We also estimate that enacting the bill would increase direct spending by $8 million in 2007, by $67 million over the 2007-2011 period, and by $163 million over the 2007-2016 period.

H.R. 5312 would preempt state licensing laws in certain cases, and this preemption would be an intergovernmental mandate as defined in the Unfunded Mandates Reform Act (UMRA); however, CBO estimates that the costs of that mandate would be small and would not approach the threshold established in UMRA ($64 million in 2006, adjusted annually for inflation). The bill also would place new requirements on Medicaid and the State Children's Health Insurance Program (SCHIP) that would result in additional spending of about $93 million over the 2007-2016 period. Other provisions of the bill would benefit tribal governments by establishing new or expanding existing programs for Indian health care. This bill contains no private-sector mandates as defined in UMRA.

Estimated cost to the Federal Government: The estimated budgetary impact of H.R. 5312 is shown in Table 1. The costs of this legislation fall within budget function 550 (health).

TABLE 1- ESTIMATED BUDGETARY EFFECTS OF H.R. 5312

-------------------------------------------------------------------------------------------------------------------------------------------

                                             By fiscal year, in millions of dollars--

                                                                                 2007  2008  2009  2010  2011  2012  2013  2014  2015 2016

-------------------------------------------------------------------------------------------------------------------------------------------

CHANGES IN SPENDING SUBJECT TO APPROPRIATION

Estimated Authorization Level                                                   3,117 3,188 3,261 3,336 3,412 3,491 3,571 3,654 3,740    0

Estimated Outlays                                                               2,571 2,998 3,160 3,303 3,378 3,456 3,536 3,617 3,702  634

CHANGES IN DIRECT SPENDING

Estimated Budget Authority                                                          7    14    14    15    15    15    16    21    21   22

Estimated Outlays                                                                   8    15    14    15    15    15    16    21    21   23

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Basis of estimate: For the purpose of this estimate, CBO assumes that H.R. 5312 will be enacted near the start of fiscal year 2007 and that the necessary amounts will be appropriated for each fiscal year.

Spending subject to appropriation

H.R. 5312 would authorize the appropriation of such sums as are necessary for the Indian Health Service through 2015. The agency's responsibilities under the bill would be broadly similar to those in current law. In 2006, the agency received an appropriation just over $3 billion. CBO's estimate of the authorized level for IHS programs is the appropriated amount for 2006 adjusted for anticipated inflation in later years. The estimated outlays reflect historical spending patterns for IHS activities.

Direct spending

H.R. 5312 contains several provisions, primarily related to the Medicaid program, that would affect direct spending. The bill's estimated effects on direct spending are shown in Table 2. Overall, CBO estimates that enacting the bill would increase direct spending by $8 million in 2007 and $163 million over the 2007-2016 period.

TABLE 2- ESTIMATED EFFECTS OF H.R. 5312 ON DIRECT SPENDING

----------------------------------------------------------------------------------------------------------------------------------------------------

                                                              By fiscal year, in millions of dollars--

                                                                                                  2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

----------------------------------------------------------------------------------------------------------------------------------------------------

Exemption from Cost Sharing and Premiums:

Medicaid:

Estimated Budget Authority                                                                           5   10   10   10   10   10   10   15   15   15

Estimated Outlays                                                                                    5   10   10   10   10   10   10   15   15   15

SCHlP:

Budget Authority                                                                                     0    0    0    0    0    0    0    0    0    0

Estimated Outlays                                                                                    1    1    *   -1    *    *    *    *    *    *

Consultation with Indian Health Programs:

Estimated Budget Authority                                                                           *    *    1    1    1    1    1    1    1    1

Estimated Outlays                                                                                    *    *    1    1    1    1    1    1    1    1

Medicaid Managed Care Provisions:

Estimated Budget Authority                                                                           2    3    3    4    4    4    5    5    5    6

Estimated Outlays                                                                                    2    3    3    4    4    4    5    5    5    6

Exclude Outreach Spending from Limit on Administrative Costs:

Estimated Budget Authority                                                                           *    *    *    *    *    *    *    *    *    *

Estimated Outlays                                                                                    *    *    *    *    *    *    *    *    *    *

Scholarship and Loan Repayment Recovery Fund:

Estimated Budget Authority                                                                           *    *    *    *    *    *    *    *    *    *

Estimated Outlays                                                                                    *    *    *    *    *    *    *    *    *    *

Total Changes in Direct Spending:

Estimated Budget Authority                                                                           7   14   14   15   15   15   16   21   21   22

Estimated Outlays                                                                                    8   15   14   15   15   15   16   21   21   23

----------------------------------------------------------------------------------------------------------------------------------------------------

The effects of each provision are discussed in more detail below. IHS-funded health programs are commonly divided into three groups: those operated directly by the Indian Health Service, those operated by tribes and tribal organizations under self-governance agreements, and those operated by urban Indian organizations. For this estimate, they are referred to collectively as Indian health programs.

Exemption from Cost Sharing and Premiums. Section 204 would prohibit Medicaid and SCHIP programs from charging cost sharing or premiums to Indians for services that are provided directly or upon referral by Indian health programs. The provision also would prohibit states from reducing payments to providers for those services by the amount of cost sharing that Indians otherwise would pay.

Medicaid. CBO anticipates that this provision's budgetary effect would stem largely from eliminating cost sharing for referral services. Current law already prohibits Indian health programs from charging cost sharing to Indians who use their services. In addition, Medicaid pays almost all facilities operated by IHS and tribes based on an all-inclusive rate that is not reduced to account for any cost sharing that Indians would otherwise have to pay. Finally, very few states charge premiums to their Medicaid enrollees.

Using Medicaid administrative data, CBO estimates that about 270,000 Indians are Medicaid recipients who also use IHS, and that federal Medicaid spending on affected services would be about $275 per person annually in 2007. The amount of affected spending would be relatively low because Medicaid already prohibits cost sharing in many instances, such as long-term care services, emergency services, and services for many children and pregnant women. For the affected spending, CBO assumes that cost sharing paid by individuals equals 2 percent of total spending--Medicaid law limits the extent to which states can impose cost sharing--and that eliminating cost sharing would increase total spending by about 5 percent as individuals consume more services. Overall, CBO estimates that the provision would increase federal Medicaid spending by $5 million in 2007 and by $110 million over the 2007-2016 period.

State Children's Health Insurance Program. SCHIP regulations already prohibit states from charging cost sharing or premiums to Indian children enrolled in the program. As a result, the provision's impact on SCHIP spending largely reflects higher payments to Indian health programs and the use of additional services by adult enrollees that a handful of states cover in waiver programs. CBO estimates that the additional spending would total $2 million over the 2007-2016 period. The provision's effects would be limited in later years because total funding for the program is capped.

Consultation with Indian Health Programs. Section 206 would encourage state Medicaid programs to consult regularly with Indian health programs on outstanding Medicaid issues by allowing states to receive federal matching funds for the cost of those consultations. Those costs would be treated as an administrative expense under Medicaid and divided equally between the federal government and the states. CBO anticipates that a small number of states would take advantage of this provision, increasing federal Medicaid spending by less than $500,000 in 2007 and by $7 million over the 2007-2016 period.

Medicaid Managed Care Provisions. Section 208 would make several changes to improve the ability of Indian health programs to receive payments for Indians who receive Medicaid benefits through managed care arrangements. Those changes include:

Managed care organizations (MCOs) would have to pay Indian health programs at least the rates used for preferred providers. States also would have the option of making those payments directly to Indian health programs.

MCOs would have to accept claims submitted by Indian health programs instead of requiring enrollees to submit claims personally.

Some requirements that MCOs must now meet to participate in Medicaid would be waived or modified for Indian health programs that seek to operate as MCOs. (For example, MCOs run by Indian health programs would be able to limit enrollment to Indians only.)

States would be required to offer contracts to Indian health programs seeking to operate their own MCOs.

Based on administrative data on Medicaid enrollment and spending for Indians who receive benefits via managed care, CBO estimates that those provisions would increase federal Medicaid spending by $2 million in 2007 and $41 million over the 2007-2016 period. We anticipate that the additional costs would be relatively modest because some states already use similar rules in their Medicaid managed care programs and Indian health programs would have a limited interest in participating as MCOs.

Exclude Outreach Spending from Limit on Administrative Costs. Under current law, spending by SCHIP programs on administration and certain other activities cannot exceed 10 percent of overall spending. Section 203 would exclude spending on outreach activities to enroll additional Indian children from the 10 percent limit.

CBO estimates that this provision would increase or decrease SCHIP spending by less than $500,000 in any fiscal year. Federal funding for SCHIP is limited, and we anticipate that most states with a significant Indian population would spend all of their SCHIP funds under current law. In addition, some of the states with unspent funds are not currently constrained by the 10 percent limit and thus would not be affected by the provision.

Scholarship and Loan Repayment Recovery Fund. H.R. 5312 would allow the Secretary of Health and Human Services to spend amounts collected for breach of contract from recipients of certain IHS scholarships. Under current law, those funds are deposited in the Treasury and not spent. Because the Secretary's ability to spend those funds would not be subject to appropriation, the provision would increase direct spending. Based on historical information from IRS, CBO estimated that the provision would increase spending by less than $500,000 a year and about $4 million over the 2007-2016 period.

Estimated long-term direct spending effects: Pursuant to section 407 of H. Con. Res. 95 (the Concurrent Resolution on the Budget, Fiscal Year 2006), CBO estimates that enacting H.R. 5312 would not cause an increase in direct spending greater than $5 billion in any of the 10-year periods from 2016 to 2055.

Estimated impact on state, local, and tribal governments

Intergovernmental mandates

H.R. 5312 would preempt state licensing laws in cases where a health care professional is licensed in one state but is performing services in another state under a contract or compact with a tribal health program. This preemption would be an intergovernmental mandate as defined in the UMRA; however, CBO estimates that the loss of any licensing fees resulting from the mandate would be small and would not approach the threshold established in UMRA ($64 million in 2006, adjusted annually for inflation).

Other impacts

H.R. 5312 would reauthorize and expand grant and assistance programs available to Indian tribes, tribal organizations, and urban Indian organizations for a range of health care programs, including prevention, treatment, and ongoing care. The bill also would allow IRS and tribal entities to share facilities, and it would authorize joint ventures between IRS and Indian tribes or tribal organizations for the construction and operation of health facilities. The bill would authorize funding for a variety of health services including hospice care, long-term care, public health services, and home and community-based services.

The bill would prohibit states from charging cost sharing or premiums in the Medicaid or SCHIP programs to Indians who receive services or benefits through an Indian health program. CBO estimates that the new requirements in the bill would result in additional spending by states of about $93 million over the 2007-2016 period. Some tribal entities, particularly those operating managed care systems, may realize some savings as a result of these provisions.

Estimated impact on the private sector: This bill contains no private-sector mandates as defined in UMRA.

Previous CBO estimates: On April 26, 2006, CBO transmitted a cost estimate for S. 1057, the Indian Health Care Improvement Act Amendments of 2005, as reported by the Senate Committee on Indian Affairs on March 16, 2006. That bill contains provisions that would affect direct spending that are similar to those in H.R. 5312; we estimated that enacting S. 1057 would increase direct spending by $27 million in 2007 and by $398 million over the 2007-2016 period. The estimated costs for S. 1057 are higher largely because that bill would exempt all Indians enrolled in Medicaid or SCHIP from any cost sharing or premiums. By comparison, the exemption in H.R. 5312 would apply to fewer individuals (Medicaid or SCHIP recipients who also use IHS) and to a narrower range of services (those provided directly or upon referral by Indian health programs).

On July 10, 2006, CBO transmitted a cost estimate for S. 3524, the Medicare, Medicaid, and SCRIP Indian Health Care Improvement Act of 2006, as reported by the Senate Committee on Finance on June 15, 2006. The provisions in H.R. 5312 that would affect Medicaid and SCHIP spending are identical to S. 3524, and CBO's estimates of their budgetary effects are the same.

Estimate prepared by: Federal costs: Eric Rollins. Impact on state, local, and tribal governments: Leo Lex. Impact on the private sector: Paige Shevlin.

Estimate approved by: Peter H. Fontaine, Deputy Assistant Director for Budget Analysis.

COMPLIANCE WITH PUBLIC LAW 104-4

This bill contains no unfunded mandates.

PREEMPTION OF STATE, LOCAL OR TRIBAL LAW

This bill is not intended to preempt any State, local or tribal law other than State licensing laws in certain cases where a health care professional is licensed in one State but is performing services in another State under a contract or compact with a tribal health program.

CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

In compliance with clause 3(e) of rule XIII of the Rules of the House of Representatives, changes in existing law made by the bill, as reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new matter is printed in italic, existing law in which no change is proposed is shown in roman):

INDIAN HEALTH CARE IMPROVEMENT ACT

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled

[ That this Act may be cited as the `Indian Health Care Improvement Act'. ]

[Struck out->]`[ FINDINGS ]`[<-Struck out]

[ SEC. 2. The Congress finds the following: ]

[ (a) Federal health services to maintain and improve the health of the Indians are consonant with and required by the Federal Government's historical and unique legal relationship with, and resulting responsibility to, the American Indian people. ]

[ (b) A major national goal of the United States is to provide the quantity and quality of health services which will permit the health status of Indians to be raised to the highest possible level and to encourage the maximum participation of Indians in the planning and management of those services. ]

[ (c) Federal health services to Indians have resulted in a reduction in the prevalence and incidence of preventable illnesses among, and unnecessary and premature deaths of, Indians. ]

[ (d) Despite such services, the unmet health needs of the American Indian people are severe and the health status of the Indians is far below that of the general population of the United States. ]

[Struck out->]`[ DECLARATION OF HEALTH OBJECTIVES ]`[<-Struck out]

[ SEC. 3. (a) The Congress hereby declares that it is the policy of this Nation, in fulfillment of its special responsibilities and legal obligation to the American Indian people, to assure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy. ]

[ (b) It is the intent of the Congress that the Nation meet the following health status objectives with respect to Indians and urban Indians by the year 2000: ]

[ (1) Reduce coronary heart disease deaths to a level of no more than 100 per 100,000. ]

[ (2) Reduce the prevalence of overweight individuals to no more than 30 percent. ]

[ (3) Reduce the prevalence of anemia to less than 10 percent among children aged 1 through 5. ]

[ (4) Reduce the level of cancer deaths to a rate of no more than 130 per 100,000. ]

[ (5) Reduce the level of lung cancer deaths to a rate of no more than 42 per 100,000. ]

[ (6) Reduce the level of chronic obstructive pulmonary disease related deaths to a rate of no more than 25 per 100,000. ]

[ (7) Reduce deaths among men caused by alcohol-related motor vehicle crashes to no more than 44.8 per 100,000. ]

[ (8) Reduce cirrhosis deaths to no more than 13 per 100,000. ]

[ (9) Reduce drug-related deaths to no more than 3 per 100,000. ]

[ (10) Reduce pregnancies among girls aged 17 and younger to no more than 50 per 1,000 adolescents. ]

[ (11) Reduce suicide among men to no more than 12.8 per 100,000. ]

[ (12) Reduce by 15 percent the incidence of injurious suicide attempts among adolescents aged 14 through 17. ]

[ (13) Reduce to less than 10 percent the prevalence of mental disorders among children and adolescents. ]

[ (14) Reduce the incidence of child abuse or neglect to less than 25.2 per 1,000 children under age 18. ]

[ (15) Reduce physical abuse directed at women by male partners to no more than 27 per 1,000 couples. ]

[ (16) Increase years of healthy life to at least 65 years. ]

[ (17) Reduce deaths caused by unintentional injuries to no more than 66.1 per 100,000. ]

[ (18) Reduce deaths caused by motor vehicle crashes to no more than 39.2 per 100,000. ]

[ (19) Among children aged 6 months through 5 years, reduce the prevalence of blood lead levels exceeding15ug/dl and reduce to zero the prevalence of blood lead levels exceeding 25 ug/dl. ]

[ (20) Reduce dental caries (cavities) so that the proportion of children with one or more caries (in permanent or primary teeth) is no more than 45 percent among children aged 6 through 8 and no more than 60 percent among adolescents aged 15. ]

[ (21) Reduce untreated dental caries so that the proportion of children with untreated caries (in permanent or primary teeth) is no more than 20 percent among children aged 6 through 8 and no more than 40 percent among adolescents aged 15. ]

[ (22) Reduce to no more than 20 percent the proportion of individuals aged 65 and older who have lost all of their natural teeth. ]

[ (23) Increase to at least 45 percent the proportion of individuals aged 35 to 44 who have never lost a permanent tooth due to dental caries or periodontal disease. ]

[ (24) Reduce destructive periodontal disease to a prevalence of no more than 15 percent among individuals aged 35 to 44. ]

[ (25) Increase to at least 50 percent the proportion of children who have received protective sealants on the occlusal (chewing) surfaces of permanent molar teeth. ]

[ (26) Reduce the prevalence of gingivitis among individuals aged 35 to 44 to no more than 50 percent. ]

[ (27) Reduce the infant mortality rate to no more than 8.5 per 1,000 live births. ]

[ (28) Reduce the fetal death rate (20 or more weeks of gestation) to no more than 4 per 1,000 live births plus fetal deaths. ]

[ (29) Reduce the maternal mortality rate to no more than 3.3 per 100,000 live births. ]

[ (30) Reduce the incidence of fetal alcohol syndrome to no more than 2 per 1,000 live births. ]

[ (31) Reduce stroke deaths to no more than 20 per 100,000. ]

[ (32) Reverse the increase in end-stage renal disease (requiring maintenance dialysis or transplantation) to attain an incidence of no more than 13 per 100,000. ]

[ (33) Reduce breast cancer deaths to no more than 20.6 per 100,000 women. ]

[ (34) Reduce deaths from cancer of the uterine cervix to no more than 1.3 per 100,000 women. ]

[ (35) Reduce colorectal cancer deaths to no more than 13.2 per 100,000. ]

[ (36) Reduce to no more than 11 percent the proportion of individuals who experience a limitation in major activity due to chronic conditions. ]

[ (37) Reduce significant hearing impairment to a prevalence of no more than 82 per 1,000. ]

[ (38) Reduce significant visual impairment to a prevalence of no more than 30 per 1,000. ]

[ (39) Reduce diabetes-related deaths to no more than 48 per 100,000. ]

[ (40) Reduce diabetes to an incidence of no more than 2.5 per 1,000 and a prevalence of no more than 62 per 1,000. ]

[ (41) Reduce the most severe complications of diabetes as follows: ]

[ (A) End-stage renal disease, 1.9 per 1,000. ]

[ (B) Blindness, 1.4 per 1,000. ]

[ (C) Lower extremity amputation, 4.9 per 1,000. ]

[ (D) Perinatal mortality, 2 percent. ]

[ (E) Major congenital malformations, 4 percent. ]

[ (42) Confine annual incidence of diagnosed AIDS cases to no more than 1,000 cases. ]

[ (43) Confine the prevalence of HIV infection to no more than 100 per 100,000. ]

[ (44) Reduce gonorrhea to an incidence of no more than 225 cases per 100,000. ]

[ (45) Reduce chlamydia trachomatis infections, as measured by a decrease in the incidence of nongonococcal urethritis to no more than 170 cases per 100,000. ]

[ (46) Reduce primary and secondary syphilis to an incidence of no more than 10 cases per 100,000. ]

[ (47) Reduce the incidence of pelvic inflammatory disease, as measured by a reduction in hospitalization for pelvic inflammatory disease to no more than 250 per 100,000 women aged 15 through 44. ]

[ (48) Reduce viral hepatitis B infection to no more than 40 per 100,000 cases. ]

[ (49) Reduce indigenous cases of vaccine-preventable diseases as follows: ]

[ (A) Diphtheria among individuals aged 25 and younger, 0. ]

[ (B) Tetanus among individuals aged 25 and younger, 0. ]

[ (C) Polio (wild-type virus), 0. ]

[ (D) Measles, 0. ]

[ (E) Rubella, 0. ]

[ (F) Congenital Rubella Syndrome, 0. ]

[ (G) Mumps, 500. ]

[ (H) Pertussis, 1,000. ]

[ (50) Reduce epidemic-related pneumonia and influenza deaths among individuals aged 65 and older to no more than 7.3 per 100,000. ]

[ (51) Reduce the number of new carriers of viral hepatitis B among Alaska Natives to no more than 1 case. ]

[ (52) Reduce tuberculosis to an incidence of no more than 5 cases per 100,000. ]

[ (53) Reduce bacterial meningitis to no more than 8 cases per 100,000. ]

[ (54) Reduce infectious diarrhea by at least 25 percent among children. ]

[ (55) Reduce acute middle ear infections among children aged 4 and younger, as measured by days of restricted activity or school absenteeism, to no more than 105 days per 100 children. ]

[ (56) Reduce cigarette smoking to a prevalence of no more than 20 percent. ]

[ (57) Reduce smokeless tobacco use by youth to a prevalence of no more than 10 percent. ]

[ (58) Increase to at least 65 percent the proportion of parents and caregivers who use feeding practices that prevent baby bottle tooth decay. ]

[ (59) Increase to at least 75 percent the proportion of mothers who breast feed their babies in the early postpartum period, and to at least 50 percent the proportion who continue breast feeding until their babies are 5 to 6 months old. ]

[ (60) Increase to at least 90 percent the proportion of pregnant women who receive prenatal care in the first trimester of pregnancy. ]

[ (61) Increase to at least 70 percent the proportion of individuals who have received, as a minimum within the appropriate interval, all of the screening and immunization services and at least one of the counseling services appropriate for their age and gender as recommended by the United States Preventive Services Task Force. ]

[ (c) It is the intent of the Congress that the Nation increase the proportion of all degrees in the health professions and allied ]

and associated health profession fields awarded to Indians to 0.6 percent.

[ (d) The Secretary shall submit to the President, for inclusion in each report required to be transmitted to the Congress under section 801, a report on the progress made in each area of the Service toward meeting each of the objectives described in subsection (b). ]

[Struck out->]`[ DEFINITIONS ]`[<-Struck out]

[ SEC. 4. For purposes of this Act-- ]

[ (a) `Secretary', unless otherwise designated, means the Secretary of Health and Human Services. ]

[ (b) `Service' means the Indian Health Service. ]

[ (c) `Indians' or `Indian', unless otherwise designated, means any person who is a member of an Indian tribe, as defined in subsection (d) hereof, except that, for the purpose of sections 102 and 103, such terms shall mean any individual who (1), irrespective of whether he or she lives on or near a reservation, is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member, or (2) is an Eskimo or Aleut or other Alaska Native, or (3) is considered by the Secretary of the Interior to be an Indian for any purpose, or (4) is determined to be an Indian under regulations promulgated by the Secretary. ]

[ (d) `Indian tribe' means any Indian tribe, band, nation, or other organized group or community, including any Alaska Native village or group or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688), which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians. ]

[ (e) `Tribal organization' means the elected governing body of any Indian tribe or any legally established organization of Indians which is controlled by one or more such bodies or by a board of directors elected or selected by one or more such bodies (or elected by the Indian population to be served by such organization) and which includes the maximum participation of Indians in all phases of its activities. ]

[ (f) `Urban Indian' means any individual who resides in an urban center, as defined in subsection (g) hereof, and who meets one or more of the four criteria in subsection (c)(1) through (4) of this section. ]

[ (g) `Urban center' means any community which has a sufficient urban Indian population with unmet health needs to warrant assistance under title V, as determined by the Secretary. ]

[ (h) `Urban Indian organization' means a nonprofit corporate body situated in an urban center, governed by an urban Indian controlled board of directors and providing for the maximum participation of all interested Indian groups and individuals, which body is capable of legally cooperating with other public and private entities for the purpose of performing the activities described in section 503(a). ]

[ (i) `Area office' means an administrative entity including a program office, within the Indian Health Service through which services and funds are provided to the service units within a defined geographic area. ]

[ (j) `Service unit' means-- ]

[ (1) an administrative entity within the Indian Health Service, or ]

[ (2) a tribe or tribal organization operating health care programs or facilities with funds from the Service under the Indian Self-Determination Act, ]

through which services are provided, directly or by contract, to the eligible Indian population within a defined geographic area.

[ (k) `Health promotion' includes-- ]

[ (1) cessation of tobacco smoking, ]

[ (2) reduction in the misuse of alcohol and drugs, ]

[ (3) improvement of nutrition, ]

[ (4) improvement in physical fitness, ]

[ (5) family planning, ]

[ (6) control of stress, and ]

[ (7) pregnancy and infant care (including prevention of fetal alcohol syndrome). ]

[ (l) `Disease prevention' includes-- ]

[ (1) immunizations, ]

[ (2) control of high blood pressure, ]

[ (3) control of sexually transmittable diseases, ]

[ (4) prevention and control of diabetes, ]

[ (5) control of toxic agents, ]

[ (6) occupational safety and health, ]

[ (7) accident prevention, ]

[ (8) fluoridation of water, and ]

[ (9) control of infectious agents. ]

[ (m) `Service area' means the geographical area served by each area office. ]

[ (n) `Health profession' means allopathic medicine, family medicine, internal medicine, pediatrics, geriatric medicine, obstetrics and gynecology, podiatric medicine, nursing, public health nursing, dentistry, psychiatry, osteopathy, optometry, pharmacy, psychology, public health, social work, marriage and family therapy, chiropractic medicine, environmental health and engineering, an allied health profession, or any other health profession. ]

[ (o) `Substance abuse' includes inhalant abuse. ]

[ (p) `FAE' means fetal alcohol effect. ]

[ (q) `FAS' means fetal alcohol syndrome. ]

[Struck out->]`[ TITLE I--INDIAN HEALTH MANPOWER ]`[<-Struck out]

[Struck out->]`[ PURPOSE ]`[<-Struck out]

[ SEC. 101. The purpose of this title is to increase the number of Indians entering the health professions and to assure an adequate supply of health professionals to the Service, Indian tribes, tribal organizations, and urban Indian organizations involved in the provision of health care to Indian people. ]

[Struck out->]`[ HEALTH PROFESSIONS RECRUITMENT PROGRAM FOR INDIANS ]`[<-Struck out]

[ SEC. 102. (a) The Secretary, acting through the Service, shall make grants to public or nonprofit private health, or educational entities, or Indian tribes or tribal organizations to assist such entities in meeting the costs of-- ]

[ (1) identifying Indians with a potential for education or training in the health professions and encouraging and assisting them-- ]

[ (A) to enroll in courses of study in such health professions; or ]

[ (B) if they are not qualified to enroll in any such courses of study, to undertake such postsecondary education or training as may be required to qualify them for enrollment; ]

[ (2) publicizing existing sources of financial aid available to Indians enrolled in any course of study referred to in paragraph (1) of this subsection or who are undertaking training necessary to quality them to enroll in any such course of study; or ]

[ (3) establishing other programs which the Secretary determines will enhance and facilitate the enrollment of Indians in, and the subsequent pursuit and completion by them of, courses of study referred to in paragraph (1) of this subsection. ]

[ (b)(1) No grant may be made under this section unless an application therefor has been submitted to, and approved by, the Secretary. Such application shall be in such form, submitted in such manner, and contain such information, as the Secretary shall by regulation prescribe. The Secretary shall give a preference to applications submitted by Indian tribes or tribal organizations. ]

[ (2) The amount of any grant under this section shall be determined by the Secretary. Payments pursuant to grants under this section may be made in advance or by way of reimbursement, and at such intervals and on such conditions as the Secretary finds necessary. ]

[Struck out->]`[ HEALTH PROFESSIONS PREPARATORY SCHOLARSHIP PROGRAM FOR INDIANS ]`[<-Struck out]

[ SEC. 103. (a) The Secretary, acting through the Service, shall make scholarship grants to Indians who-- ]

[ (1) have successfully completed their high school education or high school equivalency; and ]

[ (2) have demonstrated the capability to successfully complete courses of study in the health professions. ]

[ (b) Scholarship grants made pursuant to this section shall be for the following purposes: ]

[ (1) Compensatory preprofessional education of any grantee, such scholarship not to exceed two years on a full-time basis (or the part-time equivalent thereof, as determined by the Secretary). ]

[ (2) Pregraduate education of any grantee leading to a baccalaureate degree in an approved course of study preparatory to a field of study in a health profession, such scholarship not to exceed 4 years (or the part-time equivalent thereof, as determined by the Secretary). ]

[ (c) Scholarship grants made under this section may cover costs of tuition, books, transportation, board, and other necessary related expenses of a grantee while attending school. ]

[ (d) The Secretary shall not deny scholarship assistance to an eligible applicant under this section solely on the basis of the applicant's scholastic achievement if such applicant has been admitted to, or maintained good standing at, an accredited institution. ]

[ (e) The Secretary shall not deny scholarship assistance to an eligible applicant under this section solely by reason of such applicant's eligibility for assistance or benefits under any other Federal program. ]

[Struck out->]`[ INDIAN HEALTH PROFESSIONS SCHOLARSHIPS ]`[<-Struck out]

[ SEC. 104. (a) In order to provide health professionals to Indians, Indian tribes, tribal organizations, and urban Indian organizations, the Secretary, acting through the Service and in accordance with this section, shall make scholarship grants to Indians who are enrolled full or part time in appropriately accredited schools and pursuing courses of study in the health professions. Such scholarships shall be designated Indian Health Scholarships and shall be made in accordance with section 338A of the Public Health Service Act (42 U.S.C. 254l), except as provided in subsection (b) of this section. ]

[ (b)(1) The Secretary, acting through the Service, shall determine who shall receive scholarships under subsection (a) and shall determine the distribution of such scholarships among such health professions on the basis of the relative needs of Indians for additional service in such health professions. ]

[ (2) An individual shall be eligible for a scholarship under subsection (a) in any year in which such individual is enrolled full or part time in a course of study referred to in subsection (a). ]

[ (3)(A) The active duty service obligation under a written contract with the Secretary under section 338A of the Public Health Service Act (42 U.S.C. 254l) that an individual has entered into under that section shall, if that individual is a recipient of an Indian Health Scholarship, be met in full-time practice, by service-- ]

[ (i) in the Indian Health Service; ]

[ (ii) in a program conducted under a contract entered into under the Indian Self-Determination Act; ]

[ (iii) in a program assisted under title V of this Act; ]

[ (iv) in the private practice of the applicable profession if, as determined by the Secretary, in accordance with guidelines promulgated by the Secretary, such practice is situated in a physician or other health professional shortage area and addresses the health care needs of a substantial number of Indians; or ]

[ (B) At the request of any individual who has entered into a contract referred to in subparagraph (A) and who receives a degree in medicine (including osteopathic or allopathic medicine), dentistry, optometry, podiatry, or pharmacy, the Secretary shall defer the active duty service obligation of that individual under that contract, in order that such individual may complete any internship, ]

residency, or other advanced clinical training that is required for the practice of that health profession, for an appropriate period (in years, as determined by the Secretary), subject to the following conditions:

[ (i) No period of internship, residency, or other advanced clinical training shall be counted as satisfying any period of obligated service that is required under this section. ]

[ (ii) The active duty service obligation of that individual shall commence not later than 90 days after the completion of that advanced clinical training (or by a date specified by the Secretary). ]

[ (iii) The active duty service obligation will be served in the health profession of that individual, in a manner consistent with clauses (i) through (v) of subparagraph (A). ]

[ (C) A recipient of an Indian Health Scholarship may, at the election of the recipient, meet the active duty service obligation described in subparagraph (A) by service in a program specified in that subparagraph that-- ]

[ (i) is located on the reservation of the tribe in which the recipient is enrolled; or ]

[ (ii) serves the tribe in which the recipient is enrolled. ]

[ (D) Subject to subparagraph (C), the Secretary, in making assignments of Indian Health Scholarship recipients required to meet the active duty service obligation described in subparagraph (A), shall give priority to assigning individuals to service in those programs specified in subparagraph (A) that have a need for health professionals to provide health care services as a result of individuals having breached contracts entered into under this section. ]

[ (4) In the case of an individual receiving a scholarship under this section who is enrolled part time in an approved course of study-- ]

[ (A) such scholarship shall be for a period of years not to exceed the part-time equivalent of 4 years, as determined by the Secretary; ]

[ (B) the period of obligated service described in paragraph (3)(A) shall be equal to the greater of-- ]

[ (i) the part-time equivalent of one year for each year for which the individual was provided a scholarship (as determined by the Secretary); or ]

[ (ii) two years; and ]

[ (C) the amount of the monthly stipend specified in section 338A(g)(1)(B) of the Public Health Service Act (42 U.S.C. 254l(g)(1)(B)) shall be reduced pro rata (as determined by the Secretary) based on the number of hours such student is enrolled. ]

[ (5)(A) An individual who has, on or after the date of the enactment of this paragraph, entered into a written contract with the Secretary under this section and who-- ]

[ (i) fails to maintain an acceptable level of academic standing in the educational institution in which he is enrolled (such level determined by the educational institution under regulations of the Secretary), ]

[ (ii) is dismissed from such educational institution for disciplinary reasons, ]

[ (iii) voluntarily terminates the training in such an educational institution for which he is provided a scholarship under such contract before the completion of such training, or ]

[ (iv) fails to accept payment, or instructs the educational institution in which he is enrolled not to accept payment, in whole or in part, of a scholarship under such contract, ]

in lieu of any service obligation arising under such contract, shall be liable to the United States for the amount which has been paid to him, or on his behalf, under the contract.

[ (B) If for any reason not specified in subparagraph (A) an individual breaches his written contract by failing either to begin such individual's service obligation under this section or to complete such service obligation, the United States shall be entitled to recover from the individual an amount determined in accordance with the formula specified in subsection (l) of section 108 in the manner provided for in such subsection. ]

[ (C) Upon the death of an individual who receives an Indian Health Scholarship, any obligation of that individual for service or payment that relates to that scholarship shall be canceled. ]

[ (D) The Secretary shall provide for the partial or total waiver or suspension of any obligation of service or payment of a recipient of an Indian Health Scholarship if the Secretary determines that-- ]

[ (i) it is not possible for the recipient to meet that obligation or make that payment; ]

[ (ii) requiring that recipient to meet that obligation or make that payment would result in extreme hardship to the recipient; or ]

[ (iii) the enforcement of the requirement to meet the obligation or make the payment would be unconscionable. ]

[ (E) Notwithstanding any other provision of law, in any case of extreme hardship or for other good cause shown, the Secretary may waive, in whole or in part, the right of the United States to recover funds made available under this section. ]

[ (F) Notwithstanding any other provision of law, with respect to a recipient of an Indian Health Scholarship, no obligation for payment may be released by a discharge in bankruptcy under title 11, United States Code, unless that discharge is granted after the expiration of the 5-year period beginning on the initial date on which that payment is due, and only if the bankruptcy court finds that the nondischarge of the obligation would be unconscionable. ]

[ (c) The Secretary shall, acting through the Service, establish a Placement Office to develop and implement a national policy for the placement, to available vacancies within the Service, of Indian Health Scholarship recipients required to meet the active duty service obligation prescribed under section 338C of the Public Health Service Act (42 U.S.C. 254m) without regard to any competitive personnel system, agency personnel limitation, or Indian preference policy. ]

[Struck out->]`[ INDIAN HEALTH SERVICE EXTERN PROGRAMS ]`[<-Struck out]

[ SEC. 105. (a) Any individual who receives a scholarship grant pursuant to section 104 shall be entitled to employment in the service during any nonacademic period of the year. Periods of employment pursuant to this subsection shall not be counted in determining the fulfillment of the service obligation incurred as a condition of the scholarship grant. ]

[ (b) Any individual enrolled in a course of study in the health professions may be employed by the Service during any nonacademic period of the year. Any such employment shall not exceed one hundred and twenty days during any calendar year. ]

[ (c) Any employment pursuant to this section shall be made without regard to any competitive personnel system or agency personnel limitation and to a position which will enable the individual so employed to receive practical experience in the health profession in which he or she is engaged in study. Any individual so employed shall receive payment for his or her services comparable to the salary he or she would receive if he or she were employed in the competitive system. Any individual so employed shall not be counted against any employment ceiling affecting the Service or the Department of Health and Human Services. ]

[Struck out->]`[ CONTINUING EDUCATION ALLOWANCES ]`[<-Struck out]

[ SEC. 106. (a) In order to encourage physicians, dentists, nurses, and other health professionals to join or continue in the Service and to provide their services in the rural and remote areas where a significant portion of the Indian people resides, the Secretary, acting through the Service, may provide allowances to health professionals employed in the Service to enable them for a period of time each year prescribed by regulation of the Secretary to take leave of their duty stations for professional consultation and refresher training courses. ]

[ (b) Of amounts appropriated under the authority of this title for each fiscal year to be used to carry out this section, not more than $1,000,000 may be used to establish postdoctoral training programs for health professionals. ]

[Struck out->]`[ COMMUNITY HEALTH REPRESENTATIVE PROGRAM ]`[<-Struck out]

[ SEC. 107. (a) Under the authority of the Act of November 2, 1921 (25 U.S.C. 13), popularly known as the Snyder Act, the Secretary shall maintain a Community Health Representative Program under which the Service-- ]

[ (1) provides for the training of Indians as health paraprofessionals, and ]

[ (2) uses such paraprofessionals in the provision of health care, health promotion, and disease prevention services to Indian communities. ]

[ (b) The Secretary, acting through the Community Health Representative Program of the Service, shall-- ]

[ (1) provide a high standard of training for paraprofessionals to Community Health Representatives to ensure that the Community Health Representatives provide quality health care, health promotion, and disease prevention services to the Indian communities served by such Program, ]

[ (2) in order to provide such training, develop and maintain a curriculum that-- ]

[ (A) combines education in the theory of health care with supervised practical experience in the provision of health care, and ]

[ (B) provides instruction and practical experience in health promotion and disease prevention activities, with appropriate consideration given to lifestyle factors that have an impact on Indian health status, such as alcoholism, family dysfunction, and poverty, ]

[ (3) maintain a system which identifies the needs of Community Health Representatives for continuing education in health care, health promotion, and disease prevention and maintain programs that meet the needs for such continuing education, ]

[ (4) maintain a system that provides close supervision of Community Health Representatives, ]

[ (5) maintain a system under which the work of Community Health Representatives is reviewed and evaluated, and ]

[ (6) promote traditional health care practices of the Indian tribes served consistent with the Service standards for the provision of health care, health promotion, and disease prevention. ]

[Struck out->]`[ INDIAN HEALTH SERVICE LOAN REPAYMENT PROGRAM ]`[<-Struck out]

[ SEC. 108. (a)(1) The Secretary, acting through the Service, shall establish a program to be known as the Indian Health Service Loan Repayment Program (hereinafter referred to as the `Loan Repayment Program') in order to assure an adequate supply of trained health professionals necessary to maintain accreditation of, and provide health care services to Indians through, Indian health programs. ]

[ (2) For the purposes of this section-- ]

[ (A) the term `Indian health program' means any health program or facility funded, in whole or part, by the Service for the benefit of Indians and administered-- ]

[ (i) directly by the Service; ]

[ (ii) by any Indian tribe or tribal or Indian organization pursuant to a contract under-- ]

[ (I) the Indian Self-Determination Act, or ]

[ (II) section 23 of the Act of April 30, 1908 (25 U.S.C. 47), popularly known as the `Buy-Indian' Act; or ]

[ (iii) by an urban Indian organization pursuant to title V of this Act; and ]

[ (B) the term `State' has the same meaning given such term in section 331(i)(4) of the Public Health Service Act. ]

[ (b) To be eligible to participate in the Loan Repayment Program, an individual must-- ]

[ (1)(A) be enrolled-- ]

[ (i) in a course of study or program in an accredited institution, as determined by the Secretary, within any State and be scheduled to complete such course of study in the same year such individual applies to participate in such program; or ]

[ (ii) in an approved graduate training program in a health profession; or ]

[ (B) have-- ]

[ (i) a degree in a health profession; and ]

[ (ii) a license to practice a health profession in a State; ]

[ (2)(A) be eligible for, or hold, an appointment as a commissioned officer in the Regular or Reserve Corps of the Public Health Service; ]

[ (B) be eligible for selection for civilian service in the Regular or Reserve Corps of the Public Health Service; ]

[ (C) meet the professional standards for civil service employment in the Indian Health Service; or ]

[ (D) be employed in an Indian health program without a service obligation; and ]

[ (3) submit to the Secretary an application for a contract described in subsection (f). ]

[ (c)(1) In disseminating application forms and contract forms to individuals desiring to participate in the Loan Repayment Program, the Secretary shall include with such forms a fair summary of the rights and liabilities of an individual whose application is approved (and whose contract is accepted) by the Secretary, including in the summary a clear explanation of the damages to which the United States is entitled under subsection (l) in the case of the individual's breach of the contract. The Secretary shall provide such individuals with sufficient information regarding the advantages and disadvantages of service as a commissioned officer in the Regular or Reserve Corps of the Public Health Service or a civilian employee of the Indian Health Service to enable the individual to make a decision on an informed basis. ]

[ (2) The application form, contract form, and all other information furnished by the Secretary under this section shall be written in a manner calculated to be understood by the average individual applying to participate in the Loan Repayment Program. ]

[ (3) The Secretary shall make such application forms, contract forms, and other information available to individuals desiring to participate in the Loan Repayment Program on a date sufficiently early to ensure that such individuals have adequate time to carefully review and evaluate such forms and information. ]

[ (d)(1) Consistent with paragraph (3), the Secretary, acting through the Service and in accordance with subsection (k), shall annually-- ]

[ (A) identify the positions in each Indian health program for which there is a need or a vacancy, and ]

[ (B) rank those positions in order of priority. ]

[ (2) Consistent with the priority determined under paragraph (1), the Secretary, in determining which applications under the Loan Repayment Program to approve (and which contracts to accept), shall give priority to applications made by-- ]

[ (A) Indians; and ]

[ (B) individuals recruited through the efforts of Indian tribes or tribal or Indian organizations. ]

[ (3)(A) Subject to subparagraph (B), of the total amounts appropriated for each of the fiscal years 1993, 1994, and 1995 for loan repayment contracts under this section, the Secretary shall provide that-- ]

[ (i) not less than 25 percent be provided to applicants who are nurses, nurse practitioners, or nurse midwives; and ]

[ (ii) not less than 10 percent be provided to applicants who are mental health professionals (other than applicants described in clause (i)). ]

[ (B) The requirements specified in clause (i) or clause (ii) of subparagraph (A) shall not apply if the Secretary does not receive the number of applications from the individuals described in clause (i) or clause (ii), respectively, necessary to meet such requirements. ]

[ (e)(1) An individual becomes a participant in the Loan Repayment Program only upon the Secretary and the individual entering into a written contract described in subsection (f). ]

[ (2) The Secretary shall provide written notice to an individual promptly on-- ]

[ (A) the Secretary's approving, under paragraph (1), of the individual's participation in the Loan Repayment Program, including extensions resulting in an aggregate period of obligated service in excess of 4 years; or ]

[ (B) the Secretary's disapproving an individual's participation in such Program. ]

[ (f) The written contract referred to in this section between the Secretary and an individual shall contain-- ]

[ (1) an agreement under which-- ]

[ (A) subject to paragraph (3), the Secretary agrees-- ]

[ (i) to pay loans on behalf of the individual in accordance with the provisions of this section, and ]

[ (ii) to accept (subject to the availability of appropriated funds for carrying out this section) the individual into the Service or place the individual with a tribe or Indian organization as provided in subparagraph (B)(iii), and ]

[ (B) subject to paragraph (3), the individual agrees-- ]

[ (i) to accept loan payments on behalf of the individual; ]

[ (ii) in the case of an individual described in subsection (b)(1)-- ]

[ (I) to maintain enrollment in a course of study or training described in subsection (b)(1)(A) until the individual completes the course of study or training, and ]

[ (II) while enrolled in such course of study or training, to maintain an acceptable level of academic standing (as determined under regulations of the Secretary by the educational institution offering such course of study or training); ]

[ (iii) to serve for a time period (hereinafter in this section referred to as the `period of obligated service') equal to 2 years or such longer period as the individual may agree to serve in the full-time clinical practice of such individual's profession in an Indian health program to which the individual may be assigned by the Secretary; ]

[ (2) a provision permitting the Secretary to extend for such longer additional periods, as the individual may agree to, the period of obligated service agreed to by the individual under paragraph (1)(B)(iii); ]

[ (3) a provision that any financial obligation of the United States arising out of a contract entered into under this section and any obligation of the individual which is conditioned thereon is contingent upon funds being appropriated for loan repayments under this section; ]

[ (4) a statement of the damages to which the United States is entitled under subsection (l) for the individual's breach of the contract; and ]

[ (5) such other statements of the rights and liabilities of the Secretary and of the individual, not inconsistent with this section. ]

[ (g)(1) A loan repayment provided for an individual under a written contract under the Loan Repayment Program shall consist of payment, in accordance with paragraph (2), on behalf of the individual of the principal, interest, and related expenses on government and commercial loans received by the individual regarding the undergraduate or graduate education oftheindividual(orboth),whichloansweremadefor-- ]

[ (A) tuition expenses; ]

[ (B) all other reasonable educational expenses, including fees, books, and laboratory expenses, incurred by the individual; and ]

[ (C) reasonable living expenses as determined by the Secretary. ]

[ (2)(A) For each year of obligated service that an individual contracts to serve under subsection (f) the Secretary may pay up to $35,000 (or an amount equal to the amount specified in section 338B(g)(2)(A) of the Public Health Service Act) on behalf of the individual for loans described in paragraph (1). In making a determination of the amount to pay for a year of such service by an individual, the Secretary shall consider the extent to which each such determination-- ]

[ (i) affects the ability of the Secretary to maximize the number of contracts that can be provided under the Loan Repayment Program from the amounts appropriated for such contracts; ]

[ (ii) provides an incentive to serve in Indian health programs with the greatest shortages of health professionals; and ]

[ (iii) provides an incentive with respect to the health professional involved remaining in an Indian health program with such a health professional shortage, and continuing to provide primary health services, after the completion of the period of obligated service under the Loan Repayment Program. ]

[ (B) Any arrangement made by the Secretary for the making of loan repayments in accordance with this subsection shall provide that any repayments for a year of obligated service shall be made no later than the end of the fiscal year in which the individual completes such year of service. ]

[ (3) For the purpose of providing reimbursements for tax liability resulting from payments under paragraph (2) on behalf of an individual, the Secretary-- ]

[ (A) in addition to such payments, may make payments to the individual in an amount not less than 20 percent and not more than 39 percent of the total amount of loan repayments made for the taxable year involved; and ]

[ (B) may make such additional payments as the Secretary determines to be appropriate with respect to such purpose. ]

[ (4) The Secretary may enter into an agreement with the holder of any loan for which payments are made under the Loan Repayment Program to establish a schedule for the making of such payments. ]

[ (h) Notwithstanding any other provision of law, individuals who have entered into written contracts with the Secretary under this section, while undergoing academic training, shall not be counted against any employment ceiling affecting