,i  #aad? ,,congress  #b;d ,session  ,h4
 ,r4 #edjf  ,,9 ,,! ,,h\se ,,(          
,,repres5tatives  ,june #h1 #bjaf ,mrs4 
,noem 7= h]self1 ,mr4 ,a%=d1 ,mr4 ,smi? 
( ,nebraska1 ,mr4 ,=t5b]ry1 ,mr4 ,cram]1
 & ,ms4 ,mc,collum7 introduc$ ! foll[+  
bill2 :i* 0 ref]r$ to ! ,committee on   
,natural ,res\rces1 & 9 addition to !   
,committees on ,en]gy & ,comm]ce & ,ways
 & ,means1 = 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 ! ,indian ,heal? ,c>e 
,improvem5t ,act to improve access to   
tribal heal? c>e by provid+ = sy/emic   
,indian ,heal? ,s]vice work=ce & fund+  
allocation re=ms1 & = o!r purposes4  #a4
 ,%ort title2 table ( cont5ts  7a7 ,%ort
 title ,?is ,act may be cit$ z ! ,help+ 
,ensure ,acc\ntability1 ,lead]%ip1 &    
,tru/ 9 ,tribal ,heal?c>e ,act or !     
,,healt? ,act4  7b7 ,table ( cont5ts ,! 
table ( cont5ts ( ?is ,act is z foll[s3 
,sec4 #a4 ,%ort title2 table ( cont5ts4 

,sec4 #b4 ,f9d+s4 ,title ,i--,exp&+     
,au?orities & ,improv+ ,access to ,c>e  
,sec4 #aja4 ,s]vice hospital long-t]m   
contract pilot program4 ,sec4 #ajb4     
,exp&$ hir+ au?ority = ! ,indian ,heal? 
,s]vice4 ,sec4 #ajc4 ,removal or        
demotion ( employees4 ,sec4 #ajd4       
,improv+ timel9ess ( c>e4 ,title        
,,ii--,indian ,heal? ,s]vice ,recruitm5t
 & ,work=ce ,sec4 #bja4 ,exclusion f    
gross income = paym5ts made "u ,indian  
,heal? ,s]vice ,loan ,repaym5t ,program4
 ,sec4 #bjb4 ,cl>ify+ t c]ta9 degrees   
qualify individuals = eligibility 9 !   
,indian ,heal? ,s]vice ,loan ,repaym5t  
,program4 ,sec4 #bjc4 ,cultural         
compet5cy programs4 ,sec4 #bjd4         
,relocation reimbursem5t4 ,sec4 #bje4   
,au?ority to waive ,indian pref]5ce     
laws4 ,sec4 #bjf4 ,/reaml9+ m$ical      
volunte] cr$5tial+ process4 ,title      
,,iii--,pur*as$_/,ref]r$ ,c>e ,program  
,re=ms ,sec4 #cja4 ,codification (      
limitation on *>ges = heal? c>e         
pr(essional s]vices & non-hospital-bas$ 

c>e s\rce4 ,sec4 #cjb4 ,allocation (    
,pur*as$_/,ref]r$ ,c>e program funds4   
,sec4 #cjc4 ,pur*as$_/,ref]r$ ,c>e      
program backlog4 ,sec4 #cjd4 ,report on 
f9ancial /ability ( ,s]vice hospitals & 
facilities4  #b4 ,f9d+s ,congress f9ds !
 foll[+3 7#a7 ,! ,unit$ ,/ates ,gov]nm5t
 has a treaty obligation to provide     
heal? c>e to ,am]ican ,indians & ,alaska
 ,natives4  7#b7 ,! ,indian ,heal?      
,s]vice is ! ,f$]al ag5cy t is entru/$  
to c>ry out ?is obligation4  7#c7       
,access to high quality heal? c>e is    
critical = /rong & vibrant tribal       
communities 9 ! ,great ,pla9s ,area &   
?r\gh\t ! ,unit$ ,/ates4  7#d7 ,9 #bjaj1
 ! ,s5ate ,committee on ,indian ,affairs
 publi%$ a report titl$ ,9 ,critical    
,condition3 ,! ,urg5t ,ne$ to ,re=m !   
,indian ,heal? ,s]vice's ,ab]de5 ,area1 
:i* detail$ defici5cies1 abuses1 &      
malfeasance )9 ! ,ab]de5 ,area ( !      
,indian ,heal? ,s]vice1 n[ call$ !      
,great ,pla9s ,area4  7#e7 ,9 #bjae &   
#bjaf1 ! ,c5t]s = ,m$ic>e  ,m$icaid     

,s]vices conduct$ surveys ( ,indian     
,heal? ,s]vice hospitals 9 ! ,great     
,pla9s ,area & f\nd s]i\s /ructural     
defici5cies t put pati5ts' heal? &      
safety 9 imm$iate jeop>dy4  7#f7 ,!     
,indian ,heal? ,s]vice's failures 9 !   
,great ,pla9s ,area h result$ 9 a sev]e 
r$uction 9 access to em]g5cy c>e1       
ne$lessly long wait times1 pati5t       
suff]+1 l[ quality ( life1 & sev]al     
tragic dea?s4  7#g7 ,! ,indian ,heal?   
,s]vice is 9 ne$ ( compreh5sive re=m t w
 hold its managem5t & employees         
acc\ntable1 fo/] /rong & capable ag5cy  
lead]%ip1 & re/ore tribal memb]s' tru/ 9
 ! c>e x deliv]s4  ,i ,exp&+ ,au?orities
 & ,improv+ ,access to ,c>e  #aja4      
,s]vice hospital long-t]m contract pilot
 program ,title ,,viii ( ! ,indian      
,heal? ,c>e ,improvem5t ,act 7#be       
,u4,s4,c4 #afga7 is am5d$ by add+ at !  
end ! foll[+ new section3  #hcc4 ,s]vice
 hospital long-t]m contract pilot       
program  7a7 ,9 g5]al ,! ,secret>y1 act+
 ?r\gh ! ,s]vice1 %all implem5t a #g-ye>

 pilot program to te/ ! viability &     
advisability ( ent]+ into long-t]m      
contracts = ! op]ation ( eligible       
,s]vice hospitals ) gov]nance /ructures 
t include tribal input4  7b7 ,elem5ts   
,"u su* pilot program1 subject to       
subsection 7e71 ! foll[+ %all apply3    
7#a7 ,! ,secret>y %all select ?ree      
eligible ,s]vice hospitals 9 rural areas
 to p>ticipate 9 ! pilot program4  7#b7 
,= ea* su* p>ticipat+ hospital1 !       
,secret>y %all ent] into a long-t]m     
contract4  7#c7 ,at ea* su* p>ticipat+  
hospital1 ! ,secret>y1 9 consultation ) 
! prim>y ,indian tribes s]v$ by !       
hospital1 %all in/all a gov]n+ bo>d     
describ$ 9 subsection 7d71 :i* %all be  
responsible = ov]see+ ! local op]ation (
 ! hospital4  7c7 ,eligible ,s]vice     
hospital ,= purposes ( ?is section1 !   
t]m eligible ,s]vice hospital means a   
,s]vice hospital t furni%es s]vices 9 a 
rural area to direct s]vices tribes & ) 
respect to :i* ! ,secret>y has obta9$ ! 
p]mission ( ! prim>y ,indian tribes s]v$

 by ! hospital = ! hospital to          
p>ticipate "u ! pilot program "u ?is    
section4  7d7 ,gov]nance bo>d describ$  
,= purposes ( subsection 7b71 a         
gov]nance bo>d describ$ 9 ?is           
subsection1 ) respect to a ,s]vice      
hospital p>ticipat+ 9 ! pilot program1  
is a bo>d t satisfies ! foll[+ crit]ia3 
7#a7 ,composition  7,a7 ,9 g5]al ,!     
gov]nance bo>d is compos$1 9 accordance 
) ! be/ practices specifi$ "u p>agraph  
7#c71 ( ! foll[+ individuals3  7i7      
,repres5tatives ( ! ,s]vice1 :o %all be 
select$ by ! ,secret>y4  7ii7           
,repres5tatives ( ! ,s]vice hospital4   
7iii7 ,repres5tatives ( ea* prim>y      
,indian tribe s]v$ by ! hospital1 :o    
%all be select$ by ! respective ,indian 
tribe4  7iv7 ,exp]ts 9 heal? c>e        
adm9i/ration & deliv]y1 :o %all-- 7,i7  
be select$ by ! ,secret>y & respective  
,indian tribe2 &  7,,ii7 to ! ext5t     
possible1 locat$ 9 ! ,/ate 9 :i* !      
hospital is locat$ or o!rwise famili> ) 
su* ,/ate4  7,b7 ,vot+ rights ,9 det]m9+

 ! composition ( ! bo>d ) respect to    
vot+ rights on ! bo>d-- 7i7 ! numb] (   
vot+ memb]s repres5t+ ! ,s]vice %all be 
equal to ! numb] ( vot+ memb]s repres5t+
 ! ,indian tribes involv$2 &  7ii7 !    
numb] ( vot+ memb]s repres5t+ ! hospital
 may n be great] ?an ! numb] ( vot+     
memb]s repres5t+ ! ,s]vice or ! ,indian 
tribes involv$4  7#b7 ,duties ,!        
gov]nance bo>d %all p]=m duties 9       
accordance ) ! be/ practices specifi$ "u
 p>agraph 7#c7 & %all include develop+  
f9ancial & quality metrics & /&>ds =    
sal>ies1 recruitm5t1 ret5tion1 tra9+1 & 
dismissal ( employees ( su* hospital4   
7#c7 ,be/ practices ,! ,secret>y %all   
specify be/ practices = ! gov]nance bo>d
 describ$ 9 ?is subsection1 includ+ be/ 
practices relat+ to ! numb] ( memb]s (  
su* bo>d1 ! au?orities ( ! bo>d1 & !    
duties ( ! bo>d4  7e7 ,treatm5t (       
eligible ,s]vice hospitals curr5tly "u  
contract ,9 ! case ( an eligible ,s]vice
 hospital t is "u a curr5t contract ) ! 
,secret>y z ( ! initiation ( ! selection

 process p]iod = ! pilot program1 9 ord]
 = su* hospital to p>ticipate 9 ! pilot 
program ! ,secret>y1 ) ! agreem5t ( !   
hospital1 may--  7#a7 not)/&+ any o!r   
provision ( law1 modify or t]m9ate su*  
contract & 9 ord] = su* hospital to ent]
 into a long-t]m contract "u ! pilot    
program2 or  7#b7 ent] into a long-t]m  
contract "u ! pilot program 7& beg9 !   
pilot program7 beg9n+ on ! date aft] !  
la/ date ( su* curr5t contract4  7f7    
,long-,t]m contract def9$ ,= purposes ( 
?is section1 ! t]m long-t]m contract    
means a contract = a p]iod ( at lea/ #e 
ye>s4  7g7 ,cl>ification ,no?+ 9 ?is    
section %all be con/ru$ to inhibit a    
tribe's au?ority to ent] into a compact 
or contract "u ! ,indian                
,self-,det]m9ation & ,education         
,assi/ance ,act4  7h7 ,reports ,= ea*   
ye> ( ! pilot program1 ! ,secret>y %all 
submit a report to ,congress on !       
results ( ! program demon/rat$ dur+ !   
respective ye>4 ,ea* su* report %all    
include ! foll[+3  7#a7 ,in=mation      

relat$ to ! f9ancial heal? ( ea*        
eligible hospital p>ticipat+ 9 ! pilot  
program4  7#b7 ,in=mation on ! affect ! 
pilot program has on access to c>e4     
7#c7 ,in=mation on pati5t satisfaction )
 s]vices provid$ at su* hospitals4  7#d7
 ,! numb] ( readmissions at su*         
hospitals4  7#e7 ,! numb] (             
hospital-acquir$ conditions at su*      
hospitals4  7#f7 ,recomm5dations on !   
viability & advisability ( ! long-t]m   
contracts & hospital gov]nance /ructure 
"u su* pilot program4  7#g7 ,any o!r    
in=mation ! ,secret>y consid]s necess>y 
= a prop] analysis ( ! pilot program4  4
  #ajb4 ,exp&$ hir+ au?ority = ! ,indian
 ,heal? ,s]vice ,section #fja7;d7 ( !   
,indian ,heal? ,c>e ,improvem5t ,act    
7#be ,u4,s4,c4 #affa7;d77 is am5d$--    
7#a7 9 p>agraph 7#a77;,a71 by ins]t+ &  
subject to p>agraph 7#d7 aft] p>agraph  
7#b72 &  7#b7 by add+ at ! end ! foll[+3
  7#d7 ,employm5t au?ority  7,a7 ,9     
g5]al ,! ,secret>y may1 ) respect to any
 employee describ$ 9 subp>agraph 7,b71  

provide t "o or m provisions ( *apt] #gd
 ( title #ch1 ,unit$ ,/ates ,code 7o!r  
?an sub*apt] ,v ( su* *apt] or (        
regulations promulgat$ "u su* *apt] o!r 
?an "u su* sub*apt]71 %all apply--  7i7 
9 lieu ( any provision ( title #e ( !   
,unit$ ,/ates ,code 7o!r ?an z appli$   
pursuant to section #hcd72 or  7ii7     
not)/&+ any lack ( specific au?ority = a
 matt] ) respect to :i* title #e ( !    
,unit$ ,/ates ,code relates4  7,b7      
,applicability to employees ,au?ority "u
 ?is p>agraph may be ex]cis$ ) respect  
to any employee 9 ! ,s]vice hold+ a     
position--  7i7 to :i* *apt] #ea ( title
 #e ( ! ,unit$ ,/ates ,code applies1    
exclud+ any s5ior executive s]vice      
position2 &  7ii7 :i* involves heal? c>e
 responsibilities4  7,c7 ,def9ition ,=  
purposes ( ?is p>agraph1 heal? c>e means
 direct pati5t-c>e s]vices or s]vices   
incid5t to direct pati5t-c>e s]vices4  4
  #ajc4 ,removal or demotion ( employees
  7a7 ,9 g5]al ,title ,,viii ( ! ,indian
 ,heal? ,c>e ,improvem5t ,act 7#be      

,u4,s4,c4 #afga et seq471 z am5d$ by    
section #aja1 is fur!r am5d$ by add+ at 
! end ! foll[+ new section3  #hcd4      
,removal or demotion ( employees  7a7 ,9
 g5]al ,! ,secret>y may remove or demote
 an individual :o is an employee ( !    
,s]vice if ! ,secret>y det]m9es !       
p]=mance or misconduct ( ! individual   
w>rants su* removal or demotion4 ,if !  
,secret>y s removes or demotes su* an   
individual1 ! ,secret>y may--  7#a7     
remove ! individual f ! ,s]vice2 or     
7#b7 demote ! individual by means (--   
7,a7 a r$uction 9 grade = :i* !         
individual is qualifi$ & t ! ,secret>y  
det]m9es is appropriate2 or  7,b7 a     
r$uction 9 annual rate ( pay t !        
,secret>y det]m9es is appropriate4  ,9 !
 case ( an individual :o is remov$ "u   
p>agraph 7#a7 or demot$ "u p>agraph     
7#b71 ! ,secret>y may require su*       
individual take unpaid adm9i/rative     
leave = n long] ?an #aj consecutive "w  
days4  7b7 ,pay ( c]ta9 demot$          
individuals  7#a7 ,not)/&+ any o!r      

provision ( law1 any individual subject 
to a demotion "u subsection 7a77#b77;,a7
 %all1 beg9n+ on ! date ( su* demotion1 
receive ! annual rate ( pay applicable  
to su* grade4  7#b7 ,an individual s    
demot$ may n be plac$ on adm9i/rative   
leave or any o!r category ( paid leave  
dur+ ! p]iod dur+ :i* an appeal 7if any7
 "u ?is section is ongo+1 & may only    
receive pay if ! individual reports =   
duty4 ,if an individual s demot$ does n 
report = duty1 su* individual %all n    
receive pay or o!r b5efits pursuant to  
subsection 7e77#e74  7c7 ,notice to     
,secret>y ,n lat] ?an #cj days aft]     
remov+ or demot+ an individual "u       
subsection 7a71 ! ,s]vice %all submit to
 ! ,secret>y notice 9 writ+ ( su*       
removal or demotion & ! reason = su*    
removal or demotion4  7d7 ,proc$ure     
7#a7 ,! proc$ures "u section #geac7;b7 (
 title #e & *apt] #dc ( su* title %all n
 apply to a removal or demotion "u ?is  
section4  7#b7  7,a7 ,subject to        
subp>agraph 7,b7 & subsection 7e71 any  

removal or demotion "u subsection 7a7   
may be appeal$ to ! ,m]it ,sy/ems       
,protection ,bo>d "u section #ggja (    
title #e4  7,b7 ,an appeal "u           
subp>agraph 7,a7 ( a removal or demotion
 may only be made if su* appeal is made 
n lat] ?an sev5 days aft] ! date ( su*  
removal or demotion4  7e7 ,exp$it$      
,review by ,adm9i/rative ,judge  7#a7   
,^u receipt ( an appeal "u subsection   
7d77#b77;,a71 ! ,m]it ,sy/ems           
,protection ,bo>d %all ref] su* appeal  
to an adm9i/rative judge pursuant to    
section #ggja7;b77#a7 ( title #e4 ,!    
adm9i/rative judge %all exp$ite any su* 
appeal "u su* section &1 9 any su* case1
 %all issue a decision n lat] ?an #de   
days aft] ! date ( ! appeal4  7#b7      
,not)/&+ any o!r provision ( law1       
includ+ section #ggjc ( title #e1 !     
decision ( an adm9i/rative judge "u     
p>agraph 7#a7 %all be f9al & %all n be  
subject to any fur!r appeal4  7#c7 ,9   
any case 9 :i* ! adm9i/rative judge _c  
issue a decision 9 accordance ) !       

#de-;day requirem5t "u p>agraph 7#a71 ! 
removal or demotion is f9al4 ,9 su* a   
case1 ! ,m]it ,sy/ems ,protection ,bo>d 
%all1 )9 #ad days aft] ! date t su*     
removal or demotion is f9al1 submit to  
,congress a report t expla9s ! reasons  
:y a decision 0 n issu$ 9 accordance )  
su* requirem5t4  7#d7 ,! ,m]it ,sy/ems  
,protection ,bo>d or adm9i/rative judge 
may n /ay any removal or demotion "u ?is
 section4  7#e7 ,dur+ ! p]iod beg9n+ on 
! date on :i* an individual appeals a   
removal f ! ,s]vice "u subsection 7d7 & 
end+ on ! date t ! adm9i/rative judge   
issues a f9al decision on su* appeal1   
su* individual may n receive any pay1   
aw>ds1 bonuses1 inc5tives1 all[ances1   
diff]5tials1 /ud5t loan repaym5ts1      
special paym5ts1 or b5efits4  7#f7 ,to !
 maximum ext5t practicable1 ! ,secret>y 
%all provide to ! ,m]it ,sy/ems         
,protection ,bo>d1 & to any adm9i/rative
 judge to :om an appeal "u ?is section  
is ref]r$1 su* in=mation & assi/ance z  
may be necess>y to ensure an appeal "u  

?is subsection is exp$it$4  7f7         
,t]m9ation ( inve/igations by ,(fice (  
,special ,c\nsel ,not)/&+ any o!r       
provision ( law1 ! ,special ,c\nsel     
7e/abli%$ by section #abaa ( title #e7  
may t]m9ate an inve/igation ( a         
prohibit$ p]sonnel practice alleg$ by an
 employee or =m] employee ( ! ,dep>tm5t 
aft] ! ,special ,c\nsel provides to !   
employee or =m] employee a writt5       
/atem5t ( ! reasons = ! t]m9ation ( !   
inve/igation4 ,su* /atem5t may n be     
admissible z evid5ce 9 any judicial or  
adm9i/rative proce$+ )\t ! cons5t ( su* 
employee or =m] employee4  7g7 ,relation
 to ,title #e ,! au?ority provid$ by ?is
 section is 9 addition to ! au?ority    
provid$ by sub*apt] ,v ( *apt] #ge (    
title #e & *apt] #dc ( su* title4  7h7  
,def9itions ,9 ?is section3 7#a7 ,! t]m 
individual means an individual occupy+ a
 position at ! ,s]vice b does n         
include--  7,a7 an individual1 z t t]m  
is def9$ 9 section #gac7;g77#a72 or     
7,b7 a political appo9tee4  7#b7 ,! t]m 

grade has ! mean+ giv5 su* t]m 9 section
 #geaa7;a7 ( title #e4  7#c7 ,! t]m     
misconduct includes neglect ( duty1     
malfeasance1 or failure to accept a     
direct$ reassignm5t or to accompany a   
position 9 a transf] ( function4  7#d7  
,! t]m political appo9tee means an      
individual :o is-- 7,a7 employ$ 9 a     
position describ$ "u sections #ecab     
?r\gh #ecaf ( title #e 7relat+ to !     
,executive ,s*$ule72  7,b7 a limit$ t]m 
appo9tee1 limit$ em]g5cy appo9tee1 or   
nonc>e] appo9tee 9 ! ,s5ior ,executive  
,s]vice1 z def9$ "u p>agraphs 7#e71     
7#f71 & 7#g71 respectively1 ( section   
#cacb7;a7 ( title #e2 or  7,c7 employ$ 9
 a position ( a confid5tial or          
policy-det]m9+ "* "u s*$ule ,c ( subp>t 
,c ( "p #bac ( title #e ( ! ,code (     
,f$]al ,regulations4  4  7b7 ,con=m+    
,section #dcjc7;f7 ( title #e1 ,unit$   
,/ates ,code1 is am5d$-- 7#a7 by /rik+  
or at ! end ( p>agraph 7#b72  7#b7 by   
/rik+ ! p]iod at ! end ( p>agraph 7#c7 &
 ins]t+ 1 or2 &  7#c7 by add+ at ! end !

 foll[+3  7#d7 any removal or demotion  
"u section #hcd ( ! ,indian ,heal? ,c>e 
,improvem5t ,act4  4  #ajd4 ,improv+    
timel9ess ( c>e ,title ,,iii ( ! ,indian
 ,heal? ,c>e ,improvem5t ,act 7#be      
,u4,s4,c4 #afca et seq47 is am5d$ by    
add+ at ! end ! foll[+ new section3     
#cad4 ,/&>ds to improve timel9ess ( c>e 
7a7 ,9 g5]al ,! ,secret>y1 act+ ?r\gh ! 
,s]vice1 %all-- 7#a7 e/abli%1 by        
regulation1 /&>ds to measure ! timel9ess
 ( ! provision ( heal? c>e s]vices 9    
,s]vice facilities2 &  7#b7 make su*    
/&>ds available to all ,s]vice areas &  
,s]vice facilities4  7b7 ,data          
collection ,! ,secret>y1 act+ ?r\gh !   
,s]vice1 %all develop a process =       
,s]vice facilities to submit to !       
,secret>y data ) respect to ! /&>ds     
e/abli%$ "u subsection 7a74  4  ,,ii    
,indian ,heal? ,s]vice ,recruitm5t &    
,work=ce  #bja4 ,exclusion f gross      
income = paym5ts made "u ,indian ,heal? 
,s]vice ,loan ,repaym5t ,program  7a7 ,9
 g5]al ,section #ajh7;f77#d7 ( !        

,int]nal ,rev5ue ,code ( #aihf is am5d$ 
by ins]t+ "u section #ajh ( ! ,indian   
,heal? ,c>e ,improvem5t ,act1 aft]      
#cch;,i ( su* ,act14  7b7 ,cl]ical      
am5dm5t ,! head+ = section #ajh7;f77#d7 
( su* ,code is am5d$ by /rik+ & c]ta9 & 
ins]t+ 1 ,indian heal? s]vice loan      
repaym5t program1 & c]ta94  7c7         
,effective date ,! am5dm5ts made by ?is 
section %all apply to am\nts receiv$    
aft] ! date ( ! enactm5t ( ?is ,act4    
#bjb4 ,cl>ify+ t c]ta9 degrees qualify  
individuals = eligibility 9 ! ,indian   
,heal? ,s]vice ,loan ,repaym5t ,program 
,section #ajh ( ! ,indian ,heal? ,c>e   
,improvem5t ,act 7#be ,u4,s4,c4 #afaf;a7
 is am5d$-- 7#a7 9 subsection           
7b77#a77;,b7--  7,a7 9 clause 7i71 by   
ins]t+ 7includ+ a degree bus9ess        
adm9i/ration ) an emphasis 9 heal? c>e  
managem5t1 z def9$ by ! ,secret>y1 or a 
degree 9 heal? adm9i/ration1 hospital   
adm9i/ration1 or public heal?7 be=e !   
semicolon2 &  7,b7 9 clause 7ii71 by    
ins]t+ or a lic5se or c]tification to   

practice 9 ! field ( heal? adm9i/ration1
 hospital adm9i/ration1 bus9ess         
adm9i/ration1 or public heal?1 z        
applicable1 9 a ,/ate be=e ! semicolon2 
7#b7 9 subsection 7f77#a77;,b77iii71 by 
/rik+ #b ye>s or su* long] p]iod z !    
individual may agree to s]ve 9 ! full-"t
 cl9ical practice ( su* individual's    
pr(ession & ins]t+ #b ye>s or su* long] 
p]iod z ! individual may agree to s]ve 9
 ! full-"t practice ( su* individual's  
pr(ession 7or #d ye>s or su* long] p]iod
 z ! individual may agree to s]ve 9 !   
half-"t practice ( su* individual's     
pr(ession72 &  7#c7 9 subsection        
7g77#b77;,a71 9 ! fir/ s5t5ce-- 7,a7 by 
ins]t+ 1 9 ! case ( an individual agree+
 to s]ve 9 ! full-"t practice ( su*     
individual's pr(ession1 be=e up to      
#ce1jjj2 &  7,b7 by ins]t+ 7or1 9 ! case
 ( an individual agree+ to s]ve 9 !     
half-"t practice ( su* individual's     
pr(ession1 up to #ag1ejj7 be=e on behalf
 (4  #bjc4 ,cultural compet5cy programs 
,title ,i ( ! ,indian ,heal? ,c>e       

,improvem5t ,act 7#be ,u4,s4,c4 #afaa et
 seq47 is am5d$ by add+ at ! end !      
foll[+ new section3  #abe4 ,cultural    
compet5cy programs  7a7 ,9 g5]al ,!     
,secret>y1 act+ ?r\gh ! ,s]vice1 %all1 n
 lat] ?an "o ye> aft] ! date ( !        
enactm5t ( ?is section & = ea* ,s]vice  
area1 develop & implem5t tra9+ programs 
= cultural compet5cy = employees ( !    
,s]vice1 locum t55s m$ical provid]s1 &  
o!r contract$ employees :o "w at ,s]vice
 hospitals or o!r ,s]vice facilities &  
^: employm5t requires regul> direct     
pati5t access4  7b7 ,requir$            
p>ticipation ,not)/&+ any o!r provision 
( law1 beg9n+ ) ye>s beg9n+ aft] 7& =   
contracts ent]$ into on or aft]7 ! date 
( implem5tation ( ! tra9+ programs "u   
subsection 7a71 annual p>ticipation 9   
su* a program %all be a condition (     
employm5t 7or ( provid+ s]vices 9 !     
capacity z a locum t55 m$ical provid] or
 ( ! t]ms ( ! contract$ employm5t1 z    
applicable71 & cont9u$ employm5t 7or    
provision ( su* s]vices 9 su* capacity  

or contract$ employm5t1 z applicable71 =
 ea* employee ( ! ,s]vice1 locum t55s   
m$ical provid]1 & contract$ employee    
describ$ 9 su* subsection4 ,= purposes (
 ! previ\s s5t5ce1 an individual %all n 
be consid]$ z p>ticipat+ 9 su* a        
program1 ) respect to a ye>1 unless su* 
individual satisfies su* requirem5ts1   
includ+ te/+1 includ$ 9 su* program =   
su* ye>1 z specifi$ by ! ,secret>y4  7c7
 ,consultation ,9 develop+ a tra9+      
program "u subsection 7a7 = a ,s]vice   
area1 ! ,secret>y %all consult )        
repres5tatives ( ea* ,indian tribe s]v$ 
9 su* area4  4  #bjd4 ,relocation       
reimbursem5t ,title ,i ( ! ,indian      
,heal? ,c>e ,improvem5t ,act 7#be       
,u4,s4,c4 #afaa et seq471 z am5d$ by    
section #bjc1 is fur!r am5d$ by add+ at 
! end ! foll[+ new section3  #abf4      
,relocation reimbursem5t  7a7 ,9 g5]al  
,9 ! case ( an employee ( ! ,s]vice :o  
relocates to s]ve 9 a diff]5t capacity  
or position z an employee ( ! ,s]vice1 !
 ,secret>y %all1 subject to subsection  

7b71 (f] su* employee reimbursem5t =    
reasonable co/s associat$ ) su*         
relocation1 z det]m9$ by ! ,secret>y1   
incurr$ by su* employee if--  7#a7 su*  
relocation is to fill a position t--    
7,a7 is at a ,s]vice facility t is      
locat$ 9 a rural area or m$ically       
und]s]v$ area2 &  7,b7 _h n be5 fill$ by
 a full-"t non-contractor = a p]iod ( at
 lea/ #f mon?s2 or  7#b7 su* relocation 
is to fill a position t is = hospital   
managem5t or adm9i/ration1 z det]m9$ by 
! ,secret>y4  7b7 ,am\nt = relocation   
7#a7 ,9 g5]al ,! am\nt ( reimbursem5t to
 an employee "u subsection 7a7 %all be 9
 an am\nt t is at lea/ #ej p]c5t1 b n m 
?an #ge p]c5t1 ( ! specifi$ pay am\nt 7z
 describ$ 9 p>agraph 7#b77 ( ! employee4
  7#b7 ,specifi$ pay am\nt ,= purposes (
 p>agraph 7#a71 ! specifi$ pay am\nt1 ) 
respect to an employee1 is ! annual rate
 ( basic pay ( ! employee 9 effect at ! 
beg9n+ ( ! s]vice p]iod ( su* employee  
multipli$ by ! numb] ( ye>s 7includ+    
fractions ( a ye>7 9 ! s]vice p]iod1 n  

to exce$ #d ye>s4  7c7 ,cl>ification    
,no?+ 9 ?is section %all be con/ru$ z   
limit+ ! au?ority ( ! ,secret>y1 z 9    
exi/5ce be=e ! enactm5t ( ?is section1  
to (f] reimbursem5t = travel or         
relocation4  4  #bje4 ,au?ority to waive
 ,indian pref]5ce laws ,title ,,vi ( !  
,indian ,heal? ,c>e ,improvem5t ,act    
7#be ,u4,s4,c4 #afaa et seq47 is am5d$  
by add+ at ! end ! foll[+ new section3  
#fje4 ,au?ority to waive ,indian        
pref]5ce laws  ,to enhance recruitm5t & 
ret5tion ( employees ( ! ,s]vice1 !     
,secret>y may waive ! requirem5ts ( !   
,indian pref]5ce laws 7z def9$ 9 section
 #b7;e7 ( ,public ,law #if-ace 7#be     
,u4,s4,c4 #dgb;a7e777 ) respect to a    
p]sonnel action ) respect to a ,s]vice  
unit ) ! writt5 reque/ or resolution (  
an ,indian tribe locat$ )9 ! applicable 
,s]vice unit--  7#a7 if su* p]sonnel    
action is ) respect to a facility t has 
a p]sonnel vacancy rate ( at lea/ #bj   
p]c5t2 or  7#b7 9 ! case su* p]sonnel   
action is ) respect to a =m] employee ( 

! ,s]vice or =m] tribal employee :o 0   
remov$ f su* =m] employm5t or demot$ =  
misconduct t occurr$ dur+ ! five ye>s   
prior to ! date ( su* p]sonnel action4  
4  #bjf4 ,/reaml9+ m$ical volunte]      
cr$5tial+ process ,title ,i ( ! ,indian 
,heal? ,c>e ,improvem5t ,act 7#be       
,u4,s4,c4 #afaa et seq471 z am5d$ by    
sections #bjc & #bjd1 is fur!r am5d$ by 
add+ at ! end ! foll[+ new section3     
#abh4 ,/reaml9+ m$ical volunte]         
cr$5tial+ process  7a7 ,9 g5]al ,!      
,secret>y1 act+ ?r\gh ! ,s]vice1 %all1 9
 accordance ) subsection 7b71 implem5t a
 ,s]vice-wide c5traliz$ cr$5tial+ sy/em 
to cr$5tial lic5s$ heal? pr(essionals :o
 seek to volunte] at a ,s]vice facility4
  7b7 ,requirem5ts ,! cr$5tial+ sy/em   
implem5t$ "u subsection 7a7 %all be 9   
accordance ) ! foll[+3  7#a7 ,cr$5tial+ 
( lic5s$ heal? pr(essionals :o seek to  
volunte] at a ,s]vice facility %all     
occur at ! ,s]vice level4  7#b7         
,cr$5tial+ proc$ures "u su* sy/em %all  
be uni=m ?r\gh\t ! ,s]vice4  7#c7 ,"u   

su* sy/em1 9 ! case t su* a lic5s$ heal?
 pr(essional has successfully complet$ !
 cr$5tial+ proc$ures "u su* sy/em1 su*  
pr(essional %all be au?oriz$ to treat   
pati5ts at any ,s]vice facility or o!r  
facility )9 a ,s]vice area4  7c7        
,regulations ,! ,secret>y may promulgate
 regulations to implem5t ?is section4   
7d7 ,consultation ,! ,secret>y may      
consult ) public & private associations 
( m$ical provid]s 9 ! developm5t ( !    
cr$5tial+ sy/em "u ?is section4  7e7    
,application ,! cr$5tial+ sy/em "u ?is  
section %all apply ) respect to lic5s$  
heal? pr(essionals seek+ to volunte] )  
respect to--  7#a7 provid+ direct heal? 
c>e s]vices at a ,s]vice facility2 &    
7#b7 provid+ s]vices at facilities      
op]at$ or contract$ by a tribe1 tribal  
organization1 or urban ,indian          
organization "u ! ,indian               
,self-,det]m9ation & ,education         
,assi/ance ,act4  7f7 ,cl>ification     
,no?+ 9 ?is section %all be con/ru$ to  
inhibit a tribe's au?ority to ent] into 

a compact or contract "u ! ,indian      
,self-,det]m9ation & ,education         
,assi/ance ,act4  4  ,,iii              
,pur*as$_/,ref]r$ ,c>e ,program ,re=ms  
#cja4 ,codification ( limitation on     
*>ges = heal? c>e pr(essional s]vices & 
non-hospital-bas$ c>e s\rce  7a7        
,applicability ,! requirem5ts ( ?is     
section %all apply to-- 7#a7 heal?      
programs op]at$ by ! ,indian ,heal?     
,s]vice2  7#b7 heal? programs op]at$ by 
an urban ,indian organization ?r\gh a   
contract or grant "u title ,v ( !       
,indian ,heal? ,c>e ,improvem5t ,act1   
,public ,law #id-dcg1 z am5d$2 &  7#c7  
heal? programs op]at$ by an ,indian     
tribe or tribal organization pursuant to
 a contract or compact ) ! ,indian      
,heal? ,s]vice "u ! ,indian             
,self-,det]m9ation & ,education         
,assi/ance ,act 7#be ,u4,s4,c4 #dej et  
seq471 provid$ t ! ,indian tribe or     
tribal organization has agre$ 9 su*     
contract or compact to be b\nd by ?is   
section pursuant to section #ajh ( !    

,indian ,self-,det]m9ation & ,education 
,assi/ance ,act 7#be ,u4,s4,c4 #dejl7 & 
section #eag7;e7 ( su* ,act 7#be        
,u4,s4,c4 #deh;aaa-#af7;e771 z          
applicable4  7b7 ,def9itions ,= purposes
 ( ?is section1 ! foll[+ def9itions     
apply3 7#a7 ,! t]m notification ( a     
claim means1 ! submission ( a claim1 )  
respect to s]vices = an individual1 t   
meets ! requirem5ts ( section #acf4bd ( 
title #db1 ,code ( ,f$]al ,regulations1 
9 accordance ) ! foll[+3  7,a7 ,su*     
claim is submitt$ )9 ! applicable p]iod 
specifi$ "u su* section #acf4bd1 or if  
applicable1 section #djf ( ! ,indian    
,heal? ,c>e ,improvem5t ,act 7#be       
,u4,s4,c4 #afdf71 & includes in=mation  
necess>y to det]m9e ! relative m$ical   
ne$ = ! s]vices & ! individual's        
eligibility4  7,b7 ,! in=mation submitt$
 ) ! claim is suffici5t to-- 7i7 id5tify
 ! individual z eligible = ,indian      
,heal? ,s]vice s]vices 7su* z "n1       
address1 home or ref]r+ s]vice unit1    
tribal affiliation72  7ii7 id5tify !    

m$ical c>e provid$ 7su* z ! date (      
s]vice & description ( s]vices72 &      
7iii7 v]ify prior au?orization by !     
,indian ,heal? ,s]vice = s]vices provid$
 7su* z ! ,,ihs pur*ase ord] numb] or   
m$ical ref]ral =m7 or exemption f prior 
au?orization 7su* z copies ( p]t95t     
cl9ical in=mation = em]g5cy c>e t 0 n   
prior-au?oriz$74  7,c7 ,to be consid]$  
suffici5t notification ( a claim1 a     
claim submitt$ by a provid] or suppli] =
 paym5t %all be 9 a =mat t complies ) ! 
=mat requir$ = submission ( claims "u   
title ,,xviii ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acie et seq47 or       
recogniz$ "u section #aage ( su* ,act   
7#db ,u4,s4,c4 #acbj;d-#d74  7#b7 ,! t]m
 provid] means a provid] ( s]vices n    
gov]n$ by or subject to subp>t ,d ( "p  
#acf ( title #db1 ,code ( ,f$]al        
,regulations1 & may include a skill$    
nurs+ facility1 compreh5sive outpati5t  
rehabilitation facility1 home heal?     
ag5cy1 or hospice program4  7#c7 ,! t]m 
ref]ral means an au?orization = m$ical  

c>e by ! appropriate ord]+ (ficial 9    
accordance ) subp>t ,c ( "p #acf ( title
 #db1 ,code ( ,f$]al ,regulations4  7#d7
 ,! t]m repric+ ag5t means an entity t  
(f]s ! ,indian ,heal? ,s]vice or a      
tribe1 tribal organization1 or urban    
,indian organization disc\nt$ rates f   
public & private provid]s t are n !     
,indian ,heal? ,s]vice or a tribe1      
tribal organization1 or urban ,indian   
organization z a result ( exi/+         
contracts t ! public or private provid] 
o!r ?an ! ,indian ,heal? ,s]vice or a   
tribe1 tribal organization1 or urban    
,indian organization may h )9 !         
comm]cial heal? c>e indu/ry4  7#e7 ,!   
t]m suppli] means a physician or o!r    
practition]1 a facility1 or o!r entity  
7o!r ?an a provid]7 n already gov]n$ by 
or subject to subp>t ,d ( "p #acf (     
title #db1 ,code ( ,f$]al ,regulations1 
t furni%es items or s]vices "u ?is      
section4  7c7 ,paym5t = provid] &       
suppli] s]vices pur*as$ by ,indian heal?
 programs  7#a7 ,9 g5]al ,paym5t to     

provid]s & suppli]s = any level ( c>e   
au?oriz$ "u subp>t ,c ( "p #acf ( title 
#db1 ,code ( ,f$]al ,regulations1 by a  
,pur*as$_/,ref]r$ ,c>e program ( !      
,indian ,heal? ,s]vice1 au?oriz$ by a   
tribe or tribal organization c>ry+ out  
su* a program ( ! ,indian ,heal? ,s]vice
 "u ! ,indian ,self-,det]m9ation &      
,education ,assi/ance ,act 7#be         
,u4,s4,c4 #dej et seq471 au?oriz$ =     
pur*ase "u section #acf4ca ( su* title  
#db1 ,code ( ,f$]al ,regulations1 by an 
urban ,indian organization 7z t t]m is  
def9$ 9 #be ,u4,s4,c4 #afjc7;h77        
7h]eaft] collectively ref]r$ to z !     
,i_/,t_/,u71 %all1 subject to subsection
 7e71 be det]m9$ bas$ on "o ( ! me?ods  
describ$ 9 ! foll[+ subp>agraphs1 z     
applicable3  7,a7 ,,mfc rate me?od  7i7 
,9 g5]al ,! me?od describ$ 9 ?is        
subp>agraph is t1 subject to clause     
7ii71 9 ! case a specific am\nt = an    
item or s]vice has be5 negotiat$ ) a    
specific provid] or suppli] or its ag5t 
by ! ,i_/,t_/,u1 ! ,i_/,t_/,u %all pay t

 am\nt = su* item or s]vice4  7ii7      
,limitation ,! am\nt appli$ "u clause   
7i7 = an item or s]vice %all be an am\nt
 t is at lea/ ! am\nt ( ! provid]'s or  
suppli]'s mo/ favor$ cu/om] rate1 z     
def9$ by ! ,secret>y ( ,heal? & ,human  
,s]vices1 = an item or s]vice1 z evid5c$
 by comm]cial price li/s or paid        
invoices & o!r relat$ pric+ & disc\nt   
data to ensure t ! ,i_/,t_/,u is receiv+
 a fair & reasonable price4 ,!          
limitation "u ! previ\s s5t5ce %all n   
apply ) respect to an item or s]vice    
if--  7,i7 ! am\nt (f]$ to ! ,i_/,t_/,u 
"u ! negotiation "u clause 7i7 is fair &
 reasonable1 z det]m9$ by ! ,i_/,t_/,u1 
ev5 ?\gh comp>able disc\nts 7 n         
negotiat$2 &  7,,ii7 ! am\nt is o!rwise 
9 ! be/ int]e/ ( ! ,i_/,t_/,u1 z det]m9$
 by ! ,i_/,t_/,u4  7,b7 ,m$ic>e rates ,!
 me?od describ$ 9 ?is subp>agraph is t1 
9 ! case t an am\nt = an item or s]vice 
has n be5 negotiat$ 9 accordance )      
subp>agraph 7,a71 ! ,i_/,t_/,u w pay !  
l[e/ ( ! foll[+ am\nts = ! item or      

s]vice3  7i7 ,! am\nt t is ! applicable 
paym5t am\nt "u ! ,m$ic>e program "u    
title ,,xviii ( ! ,social ,security ,act
 = su* item or s]vice1 includ+ paym5t   
accord+ to a fee s*$ule1 a prospective  
paym5t sy/em or bas$ on reasonable co/ =
 ! p]iod 9 :i* ! s]vice 0 provid$1 or 9 
! ev5t ( a ,m$ic>e waiv]1 ! paym5t am\nt
 w be calculat$ 9 accordance ) su*      
waiv]4 ,= purposes ( ?is p>agraph1 !    
am\nt describ$ 9 ?is clause %all be     
ref]r$ to z ! ,m$ic>e rate4  7ii7 ,an   
am\nt negotiat$ by a repric+ ag5t if !  
provid] or suppli] is p>ticipat+ )9 !   
repric+ ag5t's network & ! ,i_/,t_/,u   
has a pric+ arrangem5t or contract ) t  
repric+ ag5t4  7iii7 ,an am\nt n to     
exce$ ! provid] or suppli]'s mo/ favor$ 
cu/om] rate describ$ 9 subp>agraph      
7,a77ii7 = su* item or s]vice1 z evid5c$
 by comm]cial price li/s or paid        
invoices & o!r relat$ pric+ & disc\nt   
data to ensure t ! ,i_/,t_/,u is receiv+
 a fair & reasonable price1 b only to ! 
ext5t su* evid5ce is reasonably         

accessible & available to ! ,i_/,t_/,u4 
7,c7 ,o!r ,! me?od describ$ 9 ?is       
subp>agraph is t1 9 ! case t a ,m$ic>e  
rate does n exi/ = an item or s]vice1 & 
no o!r me?od describ$ 9 a previ\s       
subp>agraph is accessible or available1 
! am\nt %all be deem$ to be #fe p]c5t ( 
au?oriz$ *>ges = su* item or s]vice4    
7#b7 ,coord9ation ( b5efits & limitation
 on recov]y ,if an ,i_/,t_/,u has       
au?oriz$ paym5t = items & s]vices       
provid$ to an individual :o is eligible 
= b5efits "u title ,,xviii ( ! ,social  
,security ,act1 title ,,xix ( su* ,act1 
or ano!r ?ird-p>ty pay]1 ! foll[+ %all  
apply3  7,a7 ,! ,i_/,t_/,u %all be !    
pay] ( la/ resort "u section #bija7;b7 (
 ! ,pati5t ,protection & ,af=dable ,c>e 
,act 7#be ,u4,s4,c4 #afbc7;b774  7,b7   
,if !re are any ?ird-p>ty pay]s1 !      
,i_/,t_/,u %all pay ! am\nt = :i* !     
pati5t is be+ held responsible aft] !   
provid] or suppli] ( s]vices has        
coord9at$ b5efits & all o!r alt]nate    
res\rces h be5 consid]$ & paid1 includ+ 

applicable copaym5ts1 d$uctibles1 &     
co9surance t are ow$ by ! pati5t4  7,c7 
,! maximum paym5t by ! ,i_/,t_/,u %all  
be only ! portion ( ! paym5t am\nt      
det]m9$ "u ?is section n cov]$ by any   
o!r pay]4  7,d7 ,! ,i_/,t_/,u paym5t may
 n exce$ ! rate calculat$ 9 accordance )
 p>agraph 7#a7 ( ?is section 7plus      
applicable co/ %>+74  7,e7 ,9 ! case    
paym5t is made "u su* title ,,xix = an  
item or s]vice su* paym5t %all be       
consid]$ paym5t 9 full & !re %all be no 
additional paym5t made by ! ,i_/,t_/,u =
 su* item or s]vice4  7#c7 ,au?oriz$    
s]vices ,paym5t %all be made only = ^?  
items & s]vices au?oriz$ by an          
,i_/,t_/,u consi/5t ) ?is section or    
section #ejc7;a7 ( ! ,indian ,heal? ,c>e
 ,improvem5t ,act 7#be ,u4,s4,c4        
#afec7;a774  7#d7 ,no additional *>ges  
7,a7 ,if an am\nt has n be5 negotiat$ "u
 p>agraph 7#a77;,a7 = an item or s]vice1
 ! provid] or suppli] %all be deem$ to h
 accept$ ! applicable paym5t am\nt "u   
p>agraph 7#a77;,b7 = su* item or s]vice 

z paym5t 9 full if--  7i7 ! item or     
s]vice 0 provid$ bas$ on a ref]ral2     
7ii7 ! provid] or suppli] submits a     
notification ( a claim = paym5t to !    
,i_/,t_/,u2 or  7iii7 ! provid] or      
suppli] accepts paym5t = ! provision (  
su* item or s]vice f ! ,i_/,t_/,u4  7,b7
 ,a paym5t made & accept$ 9 accordance )
 ?is section %all con/itute paym5t 9    
full & ! provid] or its ag5t1 or suppli]
 or its ag5t1 may n impose any          
additional *>ge--  7i7 on ! individual =
 ,i_/,t_/,u au?oriz$ items & s]vices2 or
  7ii7 = in=mation reque/$ by !         
,i_/,t_/,u or its ag5t or fiscal        
int]m$i>y = ! purposes ( paym5t         
det]m9ations or quality assurance4  7#e7
 ,notification ( claim ,! ,indian ,heal?
 ,s]vice %all n adjudicate a            
notification ( a claim t does n conta9 !
 in=mation describ$ 9 subsection 7b77#a7
 ) an approval or d5ial1 except t !     
,s]vice may reque/ fur!r in=mation f !  
individual1 or z applicable1 ! provid]  
or suppli]1 necess>y to make a decision4

 ,a notification ( a claim meet+ !      
requirem5ts specifi$ h]e9 does n        
gu>antee paym5t4  7#f7 ,rate au?oriz$   
,no s]vice %all be au?oriz$ & no paym5t 
%all be issu$ "u ?is section 9 excess ( 
! rate au?oriz$ by ?is section4  7d7    
,au?orization by an urban ,indian       
organization ,an urban ,indian          
organization may au?orize = pur*ase     
items & s]vices = an eligible urban     
,indian z ^? t]ms are def9$ 9 section #d
 ( ! ,indian ,heal? ,c>e ,improvem5t    
,act 7#be ,u4,s4,c4 #afjc7 accord+ to   
section #ejc ( su* ,act 7#be ,u4,s4,c4  
#afec7 & applicable regulations4        
,s]vices & items furni%$ by physicians &
 o!r heal? c>e pr(essionals &           
non-hospital-bas$ entities %all be      
subject to ! paym5t me?odology set =? 9 
?is section4  7e7 ,exception ,9 ! case (
 a paym5t describ$ 9 subsection 7c7 t is
 ) respect to a r>e specialty s]vice1 z 
specifi$ by ! ,secret>y ( ,heal? &      
,human ,s]vices1 or a s]vice furni%$ 9  
highly rural & m$ically und]s]v$ areas1 

z specifi$ by ! ,secret>y1 ! ,indian    
,heal? ,s]vice or tribe or tribal       
organization involv$ may negotiate an   
am\nt = su* paym5t = su* s]vice t is    
great] ?an ! paym5t am\nt t w\ld be     
recogniz$ "u title ,,xviii ( ! ,social  
,security = su* s]vice4  7f7 ,report ,n 
lat] ?an two ye>s aft] ! date ( !       
enactm5t ( ?is ,act1 ! ,secret>y (      
,heal? & ,human ,s]vices1 act+ ?r\gh !  
,director ( ! ,indian ,heal? ,s]vice1   
%all submit to ,congress a report on !  
impact ( ?is section on access to c>e "u
 ! ,pur*as$_/,ref]r$ ,c>e program1      
includ+ recomm5dations = su* legislative
 actions z ! ,secret>y det]m9es         
appropriate4  #cjb4 ,allocation (       
,pur*as$_/,ref]r$ ,c>e program funds    
7a7 ,9 g5]al ,title ,,ii ( ! ,indian    
,heal? ,c>e ,improvem5t ,act is am5d$ by
 ins]t+ aft] section #bbf 7#be ,u4,s4,c4
 #afbay7 ! foll[+ new section3  #bbg4   
,pur*as$_/,ref]r$ ,c>e program          
disbursem5t =mula  7a7 ,9 g5]al ,!      
,secret>y %all1 ) respect to !          

,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    
organization1 review ! di/ribution (    
funds pursuant to ! program & initiate  
proc$ures "u sub*apt] ,,iii ( *apt] #e (
 title #e1 ,unit$ ,/ates ,code1 to      
negotiate or promulgate regulations to  
develop & implem5t a revis$ di/ribution 
=mula 9 accordance ) ! subsequ5t        
subsections ( ?is section4  7b7         
,consid]ations ,9 develop+ ! revis$     
di/ribution =mula "u subsection 7a71 !  
,secret>y %all consid]-- 7#a7 ! ext5t to
 :i* s]vices are available at a ,s]vice 
hospital or facility ( ! ,s]vice r ?an !
 m]e exi/5ce ( su* a hospital or        
facility2  7#b7 population gr[? & !     
pot5tial = population gr[?2  7#c7 !     
socioeconomic makeup ( ! population (   
ea* contract heal? s]vice deliv]y area2 
7#d7 ! geographic makeup ( ea* contract 
heal? s]vice deliv]y area2  7#e7 ! size 

( ! hospital or facility2  7#f7 !       
relative regional co/ ( pur*as+ s]vices2
  7#g7 actual c\nts ( ,pur*as$_/,ref]r$ 
,c>e us]s2 &  7#h7 accr$itation problems
 at ! ,s]vice hospital or facility ( !  
,s]vice4  7c7 ,implem5tation deadl9e ,! 
revis$ di/ribution =mula "u subsection  
7a7 %all be implem5t$ n lat] ?an ! date 
t is #c ye>s aft] ! fir/ ,octob] #a     
foll[+ ! date ( ! enactm5t ( ?is ,act4  
7d7 ,transition  7#a7 ,9 g5]al ,not)/&+ 
any o!r provision ( law1 = ! p]iod      
beg9n+ on ! fir/ ,octob] #a foll[+ !    
date ( ! enactm5t ( ?is section & end+ !
 day be=e ! implem5tation date ( !      
revis$ di/ribution =mula "u subsection  
7a71 ! ,secret>y %all provide = !       
di/ribution ( funds1 ) respect to direct
 heal? c>e s]vices provid$ by a ,s]vice 
facility1 pursuant to !                 
,pur*as$_/,ref]r$ ,c>e program 7& )     
respect to s]vices provid$ by any o!r   
facility "u su* program1 at ! option (  
su* facility7 be consi/5t ) ! foll[+3   
7,a7 ,dur+ any portion ( su* p]iod = :i*

 a ,s]vice area has be5 designat$ z a   
high ,,ihs level area "u p>agraph       
7#b77;,b71 su* area %all n receive any  
funds pursuant to su* program 9 addition
 to ! base allotm5t det]m9$ "u !        
di/ribution =mula "u ! program = #bjaf )
 respect to su* area4  7,b7 ,9 ! case t 
dur+ su* p]iod ! am\nt ( funds made     
available to ! ,s]vice = su* di/ribution
 "u su* program is 9 excess ( ! total   
am\nts ( base allotm5ts = di/ribution "u
 su* program = #bjaf1 ! ,secret>y %all  
di/ribute su* excess am\nt1 9 accordance
 ) a me?odology specifi$ by ! ,secret>y1
 to ,s]vice areas :i* = an applicable   
portion ( su* p]iod ( excess fund+ h be5
 designat$ z a l[ ,,ihs level area "u   
p>agraph 7#b77;,a74  7#b7 ,area         
designations ,= purposes ( p>agraph     
7#a71 ! ,secret>y %all1 ) respect to ea*
 contract heal? s]vice deliv]y area--   
7,a7 review ! s]vices provid$ 9 ! area  
to det]m9e ! ,,ihs m$ical priority level
 pursuant to section #acf4bc7;e7 ( title
 #db1 ,code ( ,f$]al ,regulations1 ( su*

 s]vices2 &  7,b7 9 ! case majority1 z  
specifi$ by ! ,secret>y1 ( ! s]vices s  
provid$ 9 ! area 7 det]m9$ to h--  7i7  
su* a priority level ( a ,i or ,,ii1    
designate su* area z a l[ ,,ihs level   
area2 &  7ii7 any o!r priority level1   
designate su* area z a high ,,ihs level 
area4  7e7 ,application ( r$uction      
clause ,9 ! case ( a facility t1 z ( !  
date ( ! enactm5t ( ?is section1 is "u  
contract ) ! ,secret>y ) respect to !   
,pur*as$_/,ref]r$ ,c>e program & su*    
contract applies to a p]iod to :i*      
subsection 7d7 or ! revis$ di/ribution  
=mula "u subsection 7a7 applies1 if     
application ( subsection 7d7 or ! revis$
 di/ribution =mula results 9 !          
di/ribution ( an am\nt ( funds to su*   
facility dur+ su* p]iod t is less ?an ! 
am\nt ( funds t w\ld be provid$ dur+ su*
 p]iod to su* facility "u su* contract )
 respect to ! ,pur*as$_/,ref]r$ ,c>e    
program be=e application ( su*          
subsection 7d7 or su* revis$ di/ribution
 =mula1 respectively1 ! ,secret>y may "u

 section #ajf7;b7 ( ! ,indian           
,self-,det]m9ation & ,education         
,assi/ance ,act 7#be ,u4,s4,c4          
#dej;j-#a7;b77 r$uce su* am\nt accord+ly
 to be consi/5t ) su* subsection 7d7 or 
revis$ di/ribution =mula1 respectively4 
7f7 ,cl>ification ,no?+ 9 ?is section   
%all be con/ru$ to sup]s$e a ,tribe's   
self-gov]nance contract "u ! ,indian    
,self-,det]m9ation & ,education         
,assi/ance ,act4  7g7 ,update ,!        
,secret>y %all p]iodically1 b n m       
frequ5tly ?an once e #c ye>s & n less   
frequ5tly ?an once e five ye>s1 review  
&1 z necess>y1 update ! =mula implem5t$ 
"u subsection 7a74  7h7 ,consultation ,9
 develop+ ! =mula "u subsection 7a7 &   
review+ & mak+ updates to su* =mula "u  
subsection 7f71 ! ,secret>y %all consult
 ) ,indian tribes1 includ+ su* tribes   
consult$ = purposes ( c>ry+ out section 
#bbf4  7i7 ,reports ,n lat] ?an "o ye>  
aft] ! date ( ! enactm5t ( ?is section1 
& annually !reaft]1 ! ,secret>y %all    
submit to ,congress a report on !       

implem5tation ( ?is section4 ,ea* su*   
report %all include in=mation1 ) respect
 to ! p]iod = su* report1 on--  7#a7 !  
di/ribution ( funds = su* p]iod pursuant
 to ! ,pur*as$_/,ref]r$ ,c>e program    
among ! contract heal? s]vice deliv]y   
area1 tribes1 tribal organizations1 &   
urban ,indian organizations2  7#b7 :e!r 
dur+ su* p]iod any contract heal? s]vice
 deliv]y area1 tribe1 tribal            
organization1 or urban ,indian          
organization _h a %ortfall 9 su* fund+  
&1 if s1 ! am\nt ( su* %ortfall2 &  7#c7
 recomm5dations = su* legislative action
 z ! ,secret>y deems appropriate4  4    
7b7 ,con=m+ am5dm5ts ,section #bbf ( !  
,indian ,heal? ,c>e ,improvem5t ,act    
7#be ,u4,s4,c4 #afbay7 is am5d$--  7#a7 
9 subsection 7a7-- 7,a7 by /rik+ ,z soon
 z practicable aft] ! date ( enactm5t ( 
! ,indian ,heal? ,c>e ,improvem5t       
,reau?orization & ,ext5sion ,act ( #bjji
 & ins]t+ ,n lat] ?an #b ye>s aft] !    
date ( ! enactm5t ( section #bbg2  7,b7 
by /rik+ ! /udy & ins]t+ a /udy2 &  7,c7

 by /rik+ z reque/$ by ,congress 9 ,m>* 
#bjji1 or pursuant to section #hcj &    
ins]t+ 1 includ+ z am5d$ pursuant to    
section #bbg2  7#b7 9 subsection 7b7--  
7,a7 9 ! matt] prec$+ p>agraph 7#a71 by 
ins]t+ 1 & submit1 n lat] ?an "o ye>    
aft] ! date ( ! enactm5t ( section #bbg 
& annually !reaft]1 to ,congress a      
report on aft] pursuant to ! program2   
7,b7 9 p>agraph 7#c71 by /rik+ at ! end 
&2  7,c7 by r$esignat+ p>agraph 7#d7 z  
p>agraph 7#e72  7,d7 by ins]t+ aft]     
p>agraph 7#c7 ! foll[+ new p>agraph3    
7#d7 to det]m9e :e!r dur+ ! p]iod ( !   
report any contract heal? s]vice deliv]y
 area1 tribe1 tribal organization1 or   
urban ,indian organization _h a %ortfall
 9 su* fund+ &1 if s1 ! am\nt ( su*     
%ortfall2 &  7#e7 recomm5dations = su*  
legislative action z ! ,secret>y deems  
appropriate4  2 &  7,e7 9 p>agraph 7#e71
 z r$esignat$ by subp>agraph 7,c71 by   
ins]t+ 1 includ+ recomm5dations = su*   
legislative actions z ! ,secret>y       
det]m9es appropriate be=e ! p]iod at !  

end2 &  7#c7 by /rik+ subsection 7c74   
#cjc4 ,pur*as$_/ref]r$ c>e program      
backlog ,title ,,ii ( ! ,indian ,heal?  
,c>e ,improvem5t ,act 7#be ,u4,s4,c4    
#afba71 z am5d$ by section #cjb1 is     
fur!r am5d$ by add+ at ! end ! foll[+   
new section3  #bbh4 ,pur*as$_/,ref]r$   
,c>e program backlog  ,n lat] ?an "o ye>
 aft] ! date ( ! enactm5t ( ?is section1
 ! ,secret>y %all develop & implem5t a  
sy/em to prioritize any backlog ( unpaid
 balances "u ! ,pur*as$_/,ref]r$ ,c>e   
program = ea* ,s]vice area4 ,9 develop+ 
su* sy/em1 ! ,secret>y %all consid]--   
7#a7 ! monet>y am\nt ( ea* su* unpaid   
balance2 &  7#b7 h[ long su* balance has
 rema9$ unpaid4  4  #cjd4 ,report on    
f9ancial /ability ( ,s]vice hospitals & 
facilities ,n lat] ?an "o ye> aft] !    
date ( ! enactm5t ( ?is ,act1 !         
,comptroll] ,g5]al ( ! ,unit$ ,/ates    
%all submit to ,congress a report on    
issues relat$ to ! f9ancial /ability (  
hospitals & facilities ( ! ,indian      
,heal? ,s]vice t h exp]i5c$ sanction or 

?reat ( sanction by ! ,c5t]s = ,m$ic>e  
,m$icaid ,s]vices4 ,su* report %all     
focus on ! effects ( any rev5ues lo/ z a
 result ( ! sanction or ?reat ( sanction
 & %all include recomm5dations =        
legislative action4