,i  #aac? ,,congress  #b;d ,session  ,h4
 ,r4 #dhdc  ,,9 ,,! ,,h\se ,,(          
,,repres5tatives  ,june #aa1 #bjad ,ms4 
,mc,collum 7= h]self1 ,mr4 ,cole1 ,mr4  
,b5 ,ray ,lujn ( ,new ,mexico1 ,mr4     
,issa1 ,mr4 ,grijalva1 ,mr4 ,kl9e1 ,mr4 
,pallone1 ,mr4 ,"y ( ,alaska1 ,mr4      
,huffman1 & ,mr4 ,k9d7 introduc$ !      
foll[+ bill2 :i* 0 ref]r$ to !          
,committee on ,en]gy & ,comm]ce1 & 9    
addition to ! ,committees on ,ways &    
,means & ,natural ,res\rces1 = a p]iod  
to be subsequ5tly det]m9$ by ! ,speak]1 
9 ea* case = consid]ation ( su*         
provisions z fall )9 ! jurisdiction ( ! 
committee conc]n$  ,a ,,bill  ,to am5d  
title ,,xviii ( ! ,social ,security ,act
 to provide = a limitation "u ! ,m$ic>e 
program on *>ges = contract heal?       
s]vices provid$ to ,indians by ,m$ic>e  
provid]s ( s]vices & suppli]s4  #a4     
,%ort title ,?is ,act may be cit$ z !   
,native ,contract & ,rate ,exp5diture   
,act ( #bjad or ! ,native ,,c>e ,act (  
#bjad4  #b4 ,f9d+s ,congress makes !    

foll[+ f9d+s3  7#a7 ,f$]al heal? s]vices
 to ma9ta9 & improve ! heal? ( ,am]ican 
,indians & ,alaska ,natives are         
consonant ) & requir$ by ! ,f$]al       
,gov]nm5t's hi/orical & unique legal    
relation%ip )1 & result+ tru/           
responsibility to1 ! ,am]ican ,indian & 
,alaska ,native p4  7#b7 ,! unmet heal? 
ne$s ( ,am]ican ,indians & ,alaska      
,natives are sev]e & ! heal? /atus (    
,am]ican ,indians & ,alaska ,natives is 
f> bel[ t ( ! g5]al population ( !      
,unit$ ,/ates1 result+ 9 an av]age life 
expectancy = ,am]ican ,indians & ,alaska
 ,natives #d4b ye>s less ?an t = ! all  
races population ( ! ,unit$ ,/ates4     
7#c7 ,! ,indian ,heal? ,s]vice & tribal 
,pur*as$_/,ref]r$ ,c>e programs pur*ase 
prim>y & specialty c>e s]vices f private
 heal? c>e provid]s :5 ^? s]vices are n 
available at ,indian ,heal? ,s]vice or  
,tribal heal? facilities4  7#d7         
,available ,pur*as$_/,ref]r$ ,c>e funds 
h be5 insuffici5t to ensure access to   
c>e = ,am]ican ,indians & ,alaska       

,natives1 result+ 9 ration$ c>e &       
diagnosis & treatm5t delays t lead to ! 
ne$ = m int5sive & exp5sive treatm5t1   
fur!r r$uc+ already sc>ce               
,pur*as$_/,ref]r$ ,c>e funds4  7#e7 ,9  
#bjjc1 ,congress am5d$ title ,,xviii ( !
 ,social ,security ,act to require      
,m$ic>e-p>ticipat+ hospitals to accept  
pati5ts ref]r$ f ! ,indian ,heal?       
,s]vice & ,tribal ,pur*as$_/,ref]r$ ,c>e
 programs & to accept paym5t at no m ?an
 ,m$ic>e rates--! ,m$ic>e-l rate cap--= 
! s]vices provid$4  7#f7 ,! ,m$ic>e-l   
rate cap only applies to hospital       
s]vices1 & does n apply to o!r types (  
,m$ic>e-p>ticipat+ provid]s & suppli]s4 
7#g7 ,unlike o!r ,f$]al heal? c>e       
programs1 ! ,indian ,heal? ,s]vice &    
,tribal ,pur*as$_/,ref]r$ ,c>e programs 
cont9ue to pay full bill$ *>ges =       
non-hospital s]vices4  7#h7 ,because    
,pur*as$_/,ref]r$ programs cont9ue to   
pay full bill$ *>ges = non-hospital     
s]vices1 9 _m cases ! ,indian ,heal?    
,s]vice may only treat ! mo/ desp]ate   

,life or ,limb cases1 lead+ to _m       
undesirable heal? outcomes = ,am]ican   
,indians & ,alaska ,natives1 &          
ultimately increas+ co/s to !           
,pur*as$_/,ref]r$ ,c>e programs4  7#i7  
,on ,april #aa1 #bjac1 ! ,gov]nm5t      
,acc\ntability ,(fice releas$ a report  
f9d+ t capp+ ,pur*as$_/,ref]r$ ,c>e     
reimbursem5t at ,m$ic>e-l rates =       
nonhospital s]vices w\ld enable !       
,indian ,heal? ,s]vice to d\ble ! numb] 
( physician s]vices provid$ by add+ an  
additional #bec1jjj pati5t visits       
annually4  #c4 ,limitation on *>ges =   
c]ta9 contract heal? s]vices provid$ to 
,indians by ,m$ic>e provid]s ( s]vices &
 suppli]s  7a7 ,application to all      
provid]s ( s]vices  7#a7 ,9 g5]al       
,section #ahff7;a77#a77,u7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4           
#acie;cc7a77#a77,u77 is am5d$1 9 ! matt]
 prec$+ clause 7i71 by /rik+ 9 ! case ( 
hospitals :i* furni% inpati5t hospital  
s]vices = :i* paym5t may be made "u ?is 
title14  7#b7 ,regulations ,! ,secret>y 

( ,heal? & ,human ,s]vices %all         
promulgate regulations to acc\nt = !    
am5dm5t made by p>agraph 7#a74  7#c7    
,effective date ,! am5dm5t made by      
p>agraph 7#a7 %all apply to ,m$ic>e     
p>ticipation agreem5ts 9 effect 7or     
ent]$ into7 on or aft] ! date t is #ij  
days aft] ! date ( enactm5t ( ?is ,act4 
7b7 ,application to all suppli]s  7#a7  
,9 g5]al ,section #ahcd ( ! ,social     
,security ,act 7#db ,u4,s4,c4 #aciem7 is
 am5d$ by add+ at ! end ! foll[+ new    
subsection3  7r7 ,limitation on *>ges = 
c]ta9 contract heal? s]vices provid$ to 
,indians by suppli]s ,no paym5t may be  
made "u ?is title = an item or s]vice   
furni%$ by a suppli] 7z def9$ 9 section 
#ahfa7;d77 unless ! suppli] agrees      
7pursuant to a process e/abli%$ by !    
,secret>y7 to be a p>ticipat+ provid] ( 
m$ical & o!r heal? s]vices bo?--  7#a7  
"u ! ,pur*as$_/,ref]r$ ,c>e program     
7=m]ly ref]r$ to z ! contract heal?     
s]vices program7 fund$ by ! ,indian     
,heal? ,s]vice & op]at$ by ! ,indian    

,heal? ,s]vice1 an ,indian tribe1 or    
tribal organization 7z ^? t]ms are def9$
 9 section #d ( ! ,indian ,heal? ,c>e   
,improvem5t ,act71 ) respect to items & 
s]vices t are cov]$ "u su* program &    
furni%$ to an individual eligible = su* 
items & s]vices "u su* program2 &  7#b7 
"u any program fund$ by ! ,indian ,heal?
 ,s]vice & op]at$ by an urban ,indian   
organization ) respect to ! pur*ase (   
items & s]vices = an eligible urban     
,indian 7z ^? t]ms are def9$ 9 su*      
section #d71  9 accordance ) regulations
 promulgat$ by ! ,secret>y reg>d+ paym5t
 me?odology & rates ( paym5t 7includ+ ! 
acceptance ( no m ?an su* paym5t rate z 
paym5t 9 full = su* items & s]vices74  4
  7#b7 ,effective date ,! am5dm5t made  
by p>agraph 7#a7 %all apply to items &  
s]vices furni%$ on or aft] ! date t is  
#ij days aft] ! date ( enactm5t ( ?is   
,act4  7c7 ,limitation ,!re %all be no  
r$uction1 (fset1 or limitation to any   
appropriations made to ! ,indian ,heal? 
,s]vice "u ! ,indian ,heal? ,c>e        

,improvem5t ,act 7#be ,u4,s4,c4 #afba et
 seq471 ! ,act ( ,novemb] #b1 #aiba 7#be
 ,u4,s4,c4 #ac7 7commonly kn[n z !      
,snyd] ,act71 or any o!r provision ( law
 z a result ( ! provisions (1 includ+   
am5dm5ts made by1 ?is ,act4  7d7 ,/udies
 & reports  7#a7 ,/udy ,! ,secret>y (   
,heal? & ,human ,s]vices 79 ?is         
subsection ref]r$ to z ! ,secret>y71    
act+ ?r\gh ! ,director ( ! ,indian      
,heal? ,s]vice1 %all conduct a /udy on !
 impact ( ! am5dm5ts made by ?is section
 on access to c>e "u ! ,pur*as$_/,ref]r$
 ,c>e program ( ! ,indian ,heal?        
,s]vice4  7#b7 ,report ,n lat] ?an #b   
ye>s aft] ! date ( enactm5t ( ?is ,act1 
! ,secret>y %all submit to ,congress a  
report conta9+ ! results ( ! /udy       
conduct$ "u p>agraph 7#a71 includ+      
recomm5dations = su* legislation &      
adm9i/rative action z ! ,secret>y       
det]m9es appropriate4  7#c7 ,section    
#bai7;c7 /udy & report ,section #bai7;c7
 ( ! ,indian ,heal? ,c>e ,improvem5t    
,act 7#be ,u4,s4,c4 #afbar7c77 is am5d$ 

by /rik+ #ab mon?s aft] ! date ( !      
enactm5t ( ?is section & ins]t+ #ab     
mon?s aft] ! date ( ! enactm5t ( !      
,native ,contract & ,rate ,exp5diture   
,act ( #bjad1 & bi5nially !reaft] ?r\gh 
#bjbj4