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115th Congress   }                                     {   Rept. 115-1065
                        HOUSE OF REPRESENTATIVES
 2d Session      }                                     {      Part 1

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



 
   RESTORING ACCOUNTABILITY IN THE INDIAN HEALTH SERVICE ACT OF 2018

                                _______
                                

                December 3, 2018.--Ordered to be printed

                                _______
                                

Mr. Bishop of Utah, from the Committee on Natural Resources, submitted 
                             the following

                              R E P O R T

                        [To accompany H.R. 5874]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Natural Resources, to whom was referred 
the bill (H.R. 5874) to amend the Indian Health Care 
Improvement Act to improve the recruitment and retention of 
employees in the Indian Health Service, restore accountability 
in the Indian Health Service, improve health services, and for 
other purposes, having considered the same, report favorably 
thereon without amendment and recommend that the bill do pass.

                          Purpose of the Bill

    The purpose of H.R. 5874 is to amend the Indian Health Care 
Improvement Act to improve the recruitment and retention of 
employees in the Indian Health Service, restore accountability 
in the Indian Health Service, and improve health services.

                  Background and Need for Legislation

    The Indian Health Service (IHS) is an agency within the 
U.S. Department of Health and Human Services (HHS) which 
provides healthcare to approximately 2.2 million American 
Indians and Alaska Natives (AI/ANs) through 662 hospitals, 
clinics, and health stations on or near Indian reservations. 
The agency is headquartered in Rockville, Maryland, and is 
composed of 12 regions, or ``Areas,'' each with a separate 
headquarters.\1\ The agency offers ``direct-service'' 
healthcare, meaning care provided by federal employees; it also 
acts as a conduit for federal funds for tribes that have 
utilized the Indian Self-Determination and Education Assistance 
Act (ISDEAA)\2\ to independently operate their health 
facilities. The IHS also administers programs for Indians in 
urban areas. IHS provides an array of medical services, 
including inpatient, ambulatory, emergency, dental, public 
health nursing, and preventive health care in 36 States.
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    \1\The twelve areas of the IHS include: Alaska, Albuquerque, 
Bemidji, Billings, California, Great Plains, Nashville, Navajo, 
Oklahoma, Phoenix, Portland and Tucson.
    \2\25 U.S.C. 5304 et seq.
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    The Snyder Act of 1921\3\ provides the basic authority for 
the federal provision of health services and benefits to 
Indians because of their federally-recognized tribal status. 
However, the modern statutory basis and framework for the 
federal provision of health care to Indians is under the Indian 
Health Care Improvement Act.\4\ This law was permanently 
reauthorized in Title X of the Patient Protection and 
Affordable Care Act.\5\ As noted, the ISDEAA authorizes tribes 
to assume the administration and program direction 
responsibilities that are otherwise carried out by the federal 
government through contracts, compacts and annual funding 
agreements negotiated with the IHS. In Fiscal Year 2015, more 
than $2.7 billion of IHS appropriations were administered by a 
tribe or tribal organization through contracts or compacts and 
related agreements.
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    \3\25 U.S.C. 13.
    \4\25 U.S.C. 1601 et seq.
    \5\42 U.S.C. 18001.
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    In addition to providing direct-service healthcare to AI/
ANs, the IHS also operates the Purchased/Referred Care (PRC) 
program. This program is designed to ensure AI/ANs can obtain 
care when it is not available at IHS facilities; the program is 
somewhat like the Choice Program in the Veterans 
Administration. In short, the program will pay private 
providers to provide care to AI/ANs.
    The PRC program is seriously deficient. The IHS often 
denies PRC claims due to technicalities that are attributable 
to the program's complex and confusing referral process. This 
results in uncompensated care costs for private providers. 
Funding allocation is also a significant issue due in part to 
large cost overruns, including the provision of air and ground 
ambulance services to nearby cities that are often vast 
distances from remote Indian reservations. When PRC funding is 
tight, AI/ANs may be unable to obtain basic care except in the 
case of a life-or-limb emergency.
    PRC's problems can primarily be attributed to the formula 
the IHS uses to distribute funds across the agency. The funding 
method is called ``base funding,'' whereby each area is 
provided a base level--what it received the previous year--plus 
an annual adjustment for medical inflation and other items.\6\ 
Government auditors have concluded that Congress should require 
IHS ``to develop and use a new method to allocate all [PRC] 
program funds. . . .''\7\
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    \6\Government Accountability Office. ``Indian Health Service: 
Action Needed to Ensure Equitable Allocation of Resources for the 
Contract Health Service Program.'' June 15, 2012. GAO-12-446. http://
www.gao.gov/products/GAO-12-446.
    \7\Id. at 26.
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    The Great Plains Area (GPA) includes North Dakota, South 
Dakota, Nebraska, and Iowa. Headquartered in Aberdeen, South 
Dakota, the GPA serves over 120,000 tribal members and is home 
to some of the poorest and most rural counties in the United 
States. All IHS hospitals but one in the GPA are direct-service 
facilities.
    For decades, federally-run IHS facilities within the GPA 
have been dogged by extremely low-quality health care, and the 
GPA headquarters office has been accused of impropriety, 
nepotism, and corruption. Furthermore, the tribes served by the 
GPA are generally located on remote reservations that face 
long-term systemic problems such as high unemployment, alcohol 
and drug abuse, youth suicide epidemic, housing shortages, and 
lack of education.
    The most recent major Congressional review of the IHS GPA 
occurred in 2010. The Senate Committee on Indian Affairs (SCIA) 
held an oversight hearing detailing the serious deficiencies in 
the GPA.\8\ The hearing and its subsequent investigative 
findings were included in a report released by the SCIA in 
December 2010, colloquially referred to as the Dorgan 
Report.\9\ The Congressional inquiry included the review of 
over 140,000 pages of documents from the IHS and HHS, visits to 
GPA facilities, and interviews with IHS employees. The report 
described in vivid detail a wide range of deficiencies inside 
the GPA, related to both medical care and administrative 
procedures. Specific deficiencies included overuse of 
transfers, reassignments, details, and administrative leave to 
deal with employees with records of misconduct or poor 
performance; missing or stolen narcotics, as well as 
inconsistent pharmaceutical audits; substantial and recurring 
diversions or reduced health care services; PRC program 
mismanagement; Centers for Medicare & Medicaid Services 
accreditation problems; significant backlogs in billings and 
claims collection; and discouraging employees from 
communicating with Congress.\10\
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    \8\U.S. Senate. Committee on Indian Affairs. In Critical Condition: 
The Urgent Need to Reform the Indian Health Service's Aberdeen Area, 
September 28, 2010. 111th Congress. S. HRG. 111-873. http://
www.indian.senate.gov/sites/default/files/upload/files/63826.pdf.
    \9\U.S. Senate. Committee on Indian Affairs. In Critical Condition: 
The Urgent Need to Reform the Indian Health Service's Aberdeen Area, 
December 28, 2010. 111th Congress. (``Dorgan Report''). http://
www.indian.senate.gov/sites/default/files/upload/files/Chairman-s-
Report-In-Critical-Condition-12-28-10.pdf.
    \10\Id. at 5-6.
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    The 2010 SCIA report temporarily brought the GPA's problems 
to light but in the years that followed, the situation largely 
faded from public view. This was in part because the IHS 
repeatedly assured Congress that the issues featured in the 
SCIA report were being addressed. For example, the IHS budget 
justification accompanying the President's budget request has 
contained a paragraph related to the GPA, which says in part, 
``IHS places a high priority on the issues raised in the Senate 
Committee on Indian Affairs (SCIA) investigation of the IHS 
[GPA. . .in addition to implementing a corrective action plan 
to address findings. . .IHS will continue to implement and 
monitor improvements and corrective actions .''\11\ Each year, 
the paragraph appeared to have been copied from the previous 
year's document under the Obama Administration.\12\
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    \11\Department of Health and Human Services: Indian Health Service. 
Justification of Estimates for Appropriations Committees, Fiscal Year 
2017. Pp. CJ-150. https://www.ihs.gov/budgetformulation/includes/
themes/newihstheme/documents/FY2017CongressionalJustification.
pdf.
    \12\Department of Health and Human Services: Indian Health Service. 
Justification of Estimates for Appropriations Committees, Fiscal Year 
2016. Pp. CJ-140. https://www.ihs.gov/budgetformulation/includes/
themes/newihstheme/documents/FY2016CongressionalJustification.
pdf.
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    In March 2017, the Government Accountability Office listed 
Indian health in its biennial ``high risk'' report. Programs 
listed in the report are federal programs most vulnerable to 
waste, fraud, abuse, and mismanagement, or that need 
transformative change. For nearly a decade, the IHS Inspector 
General and others have concluded that inadequate oversight of 
healthcare continues to hinder the ability of IHS to provide an 
adequate quality of care despite continued increases in the 
agency's budget.

Recent Developments in the Great Plains Area

    The recent problems in the GPA surfaced in July 2015, when 
Centers for Medicare & Medicaid Services (CMS) terminated its 
provider contract with the Omaha-Winnebago IHS hospital in 
Nebraska, an action that CMS had threatened since the previous 
year.\13\ The termination remains in effect today, and the 
hospital struggles with basic patient safety and access.
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    \13\Kaufman, Kirby. ``Officials say Winnebago hospital will operate 
without federal funding.'' Sioux City Journal, July 24, 2015. http://
siouxcityjournal.com/news/officials-say-winnebago-
hospital-will-operate-without-federal-funding/article-5f283bb1-c660-
5848-a710-40fbc551796c.
html.
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    Since that time, CMS has surveyed three IHS hospitals in 
South Dakota; these hospitals were subsequently cited for 
quality and safety problems. The hospitals include the Rosebud, 
Pine Ridge, and Rapid City (Sioux San) service units.\14\ At 
Rosebud, the quality of care in the Emergency Department (ED) 
was found to be so poor that the IHS temporarily closed it, 
diverting all emergency cases to hospitals in Winner, South 
Dakota, and Valentine, Nebraska, 55 miles and 44 miles away 
from Rosebud, respectively. This diversion has placed serious 
physical and financial strain on the Rosebud ambulance 
system.\15\ According to Rosebud Tribal leaders, approximately 
nine patients have died in transit to these facilities since 
December 2015.\16\
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    \14\Ferguson, Dana. ``IHS hospital in `immediate jeopardy,' feds 
say. The Argus Leader, May 24, 2016. http://www.argusleader.com/story/
news/2016/05/23/reservation-hospital-immediate-jeopardy-feds-say/
84812598/.
    \15\Ferguson, Dana. ``Rosebud IHS: For some, the drive to the ER is 
too much.'' The Argus Leader, April 30, 2016. http://
www.argusleader.com/story/news/2016/04/30/rosebud-ihs-some-drive-er-
too-much/83683940/.
    \16\Ferguson, Dana. ``Death toll mounts 7 months after ER 
shuttered.'' The Argus Leader, July 7, 2016. http://
www.argusleader.com/story/news/2016/07/07/death-toll-mounts-7-months-
after-er-shuttered/86783160/.
---------------------------------------------------------------------------
    On April 30, 2016, in an unprecedented move, CMS entered 
into System Improvement Agreements (SIAs) with the IHS for the 
Pine Ridge and Rosebud hospitals. These agreements came on the 
heels of multiple corrective actions on the part of the IHS for 
both hospitals and were intended to help the IHS avoid the 
imminent loss of its ability to bill CMS at the facilities. 
While the agreements were generally considered a positive step, 
Congresswoman Kristi L. Noem (R-ND), along with Senators John 
Barrasso (R-WY), John Thune (R-SD), and Mike Rounds (R-SD), 
raised concerns about several provisions in the agreements. 
Specifically, they questioned the cost associated with the 
agreements, the lack of tribal consultation in the development 
of the agreements, and the legal basis for the IHS's authority 
to implement the agreements.\17\
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    \17\May 13, 2016 letter from Representative Kristi Noem and Sens. 
John Barrasso, John Thune, and Mike Rounds, to HHS Secretary Sylvia 
Burwell. http://www.indian.senate.gov/news/press-release/barrasso-
thune-rounds-and-noem-demand-answers-indian-health-service.
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    The largest piece of the SIAs was the requirement that the 
IHS alleviate acute staffing shortages by fully contracting the 
entire Emergency Departments for the Pine Ridge, Rosebud, and 
Winnebago hospitals (reassigning their current federal 
employees in the process).\18\ On May 17, 2016, that contract 
was awarded to a staffing agency, AB Staffing Solutions, LLC, 
located in Arizona. While AB Staffing had a previous 
relationship with the IHS, many stakeholders expressed concerns 
that the IHS's request for proposals for the contract was 
quietly released without consulting tribal leadership and 
without notifying major medical providers based in the region, 
leaving them unable to bid.\19\
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    \18\Ferguson, Dana. ``Agreement on IHS hospital could hinge on 
privatization.'' The Argus Leader, April 26, 2016. http://
www.argusleader.com/story/news/2016/04/26/agreement-ihs-
hospital-could-hinge-privatization/83534836/.
    \19\Ferguson, Dana. ``Tribal leaders say they were left out of IHS 
call for help.'' The Argus Leader, April 22, 2016. http://
www.argusleader.com/story/news/2016/04/22/tribal-leaders-say-they-were-
left-out-ihs-call-help/83386886/.
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    On June 13, 2016, due to the sudden death of a critical 
staff member, an Advanced Practice Registered Nurse 
Anesthetist, the surgical and obstetric services at Rosebud 
were temporarily diverted to Valentine, Nebraska, Martin, South 
Dakota, and Winner, South Dakota. The IHS is attempting to fill 
the position to restore surgical and obstetric services. As of 
June 2017, some of these services remained unavailable at 
Rosebud.
    In September 2016, following a CMS survey, IHS announced 
the closure of yet another IHS hospital's emergency room, this 
time in Rapid City, South Dakota. The Rapid City Service Unit 
(colloquially called ``Sioux San'' because historically, the 
building served as the ``Sioux Sanitarium'') is the primary IHS 
facility in Rapid City. Though IHS officials said this closure 
was temporary, the facility has not reopened, and all emergency 
patients are being sent to Rapid City Regional Health, a 
community hospital in Rapid City.\20\ Meanwhile, the Sioux San 
facility is operating solely as a 24-hour urgent care 
facility.\21\ This comes on the heels of months of negotiations 
between IHS and Rapid City Regional Health related to previous 
unpaid claims totaling in the tens of millions of dollars. That 
issue remains unresolved.
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    \20\Ferguson, Dana. ``Noem, Hawks criticize IHS after latest ER 
closure.'' The Argus Leader, September 14, 2016. http://
www.argusleader.com/story/news/2016/09/14/noem-hawks-criticize-ihs-
after-latest-er-closure/90346892/.
    \21\``IHS shuts down Sioux San emergency room.'' KOTA TV. September 
13, 2016. http://www.kotatv.com/content/news/IHS-shuts-down-Sioux-San-
emergency-room-393313781.html.
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    In 2016, in response to the spate of closures and 
deficiencies, HHS began marshalling resources and directing 
them toward the Great Plains. HHS, through IHS and CMS, began 
implementing procedures designed to connect IHS hospitals with 
high-performing community hospitals throughout the country. For 
example, IHS announced a $6.8 million, one-year contract with 
Avera Health, a South Dakota-based hospital system, to provide 
telehealth technology to IHS facilities in the Great Plains. On 
June 7, 2017, HHS notified Congressional staff that IHS has 
begun rolling out additional telehealth services in Nebraska, 
North Dakota, and South Dakota. IHS intends to launch ED 
telehealth services at Pine Ridge and intended to extend those 
to other facilities in Nebraska and North Dakota by the end of 
June 2017.\22\ Additionally, IHS partnered with CMS to include 
federally-operated IHS hospitals in the CMS ``Hospital 
Engagement Network,'' or HEN program. According to IHS, HENs 
are designed ``to help health care facilities deliver better 
care and to spend dollars efficiently.''\23\ The HEN program 
was established in the Patient Protection and Affordable Care 
Act to connect high-quality hospitals with other facilities to 
share best practices and encourage higher quality care at lower 
prices. Based on preliminary reports from the HEN in which 
Great Plains facilities are participating, the program has been 
moderately successful thus far.
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    \22\Email to congressional staff from HHS Acting Asst. Sec. for 
Legislation, Barbara Pisaro Clark. June 7, 2017.
    \23\Indian Health Service. ``IHS and CMS partnership to strengthen 
hospital care quality.'' 
May 13, 2016. https://www.ihs.gov/newsroom/pressreleases/
2016pressreleases/ihs-and-cms-
partnership-to-strengthen-hospital-care-quality/.
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Indian Health Service appropriations

    Congress has increased IHS funding almost each year since 
the 2010 Dorgan Report. In Fiscal Years 2014 and 2015, Congress 
exceeded President Obama's budget request for the agency. Since 
2008, funding for the IHS has increased by more than 50 
percent. The House's Fiscal Year 2017 proposed appropriation 
sits at approximately $1 billion over Fiscal Year 2010 levels, 
yet the dangerous situation in the GPA and the staffing 
shortage problem throughout the 12 IHS Areas continues to 
exist, if not grow. In the Fiscal Year 2017 omnibus 
appropriation act, Congress appropriated $2 million to address 
deficiencies in IHS hospitals with accreditation emergencies 
and $29 million to address the overall accreditation 
emergencies (which are primarily located in the Great 
Plains).\24\ In the Fiscal Year 2018 omnibus appropriations 
act, Congress appropriated $5.5 billion (an increase of $497 
million) for IHS, which includes $58 million for accreditation 
emergencies.\25\
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    \24\Public Law 115-31.
    \25\Public Law 115-141.
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Recent legislative action

    Action Two bills were introduced in the 114th Congress to 
address IHS deficiencies. Senator John Barrasso (R-WY) 
introduced S. 2953, the IHS Accountability Act.\26\ The bill 
received a legislative hearing in the form of a field hearing 
in Rapid City, South Dakota, and was later marked up by the 
Indian Affairs Committee. In the House of Representatives, 
Congresswoman Kristi Noem introduced H.R. 5406, the Helping 
Ensure Accountability, Leadership, and Trust in Tribal 
Healthcare Act--or HEALTTH Act--with several bipartisan 
cosponsors. The bill received a legislative hearing in the 
Natural Resources Committee's Subcommittee on Indian, Insular, 
and Alaska Native Affairs.\27\ No further action was taken 
before the end of the Congress.
---------------------------------------------------------------------------
    \26\S. 2953, IHS Accountability Act of 2016. https://
www.congress.gov/bill/114th-congress/
senate-bill/
2953?q=%7B%22search%22%3A%5B%22ihs+accountability+act%22%5D%7D&r;=2.
    \27\https://naturalresources.house.gov/calendar/
eventsingle.aspx?EventID=400894.
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    At the beginning of the 115th Congress, a bill entitled 
Restoring Accountability in the IHS Act of 2017 was introduced 
in both the House and Senate as H.R. 2662 and S. 1250, 
respectively. The bill was a compromise that contained 
provisions of both S. 2953 and H.R. 5406 from the previous 
Congress. A hearing was held on S. 1250 on June 13, 2017,\28\ 
and the bill was ordered reported on April 11, 2018. The House 
Natural Resources Committee held a hearing on H.R. 2662 on June 
21, 2017.\29\ Since the hearings, the committees of 
jurisdiction in the House and Senate have continued to receive 
feedback from Indian tribes, tribal organizations, the IHS and 
other stakeholders.
---------------------------------------------------------------------------
    \28\Legislative Hearing. https://www.indian.senate.gov/hearing/
legislative-hearing-receive-
testimony-following-bills-s-1250-s-1275.
    \29\Legislative Hearing: https://naturalresources.house.gov/
calendar/eventsingle.aspx?EventID=
402163.
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    On May 18, 2018, Congresswoman Kristi Noem introduced a 
revised version of H.R. 2662 as H.R. 5874. The reintroduced 
bill is substantially like S. 1250, as ordered reported. The 
bill also contains clarifying and technical amendment language 
addressing comments received to date.
    H.R. 5874 would amend the Indian Health Care Improvement 
Act (IHCIA)\30\ to improve the IHS by reforming the agency's 
personnel processes, medical credentialing system, fiscal 
accountability, and other operations. Specifically, the bill 
provides IHS broader hiring authority, and makes it easier to 
discipline and fire underperforming employees. Section 102 of 
this legislation prescribes that once a health care provider, 
who intends to volunteer their services, satisfies the 
requirements of the centralized credentialing system and 
obtains the requisite credentials from the IHS, those providers 
shall be deemed approved to provide services at any service 
unit under the control of the IHS without being further 
subjected to additional processes and procedures to obtain 
privileges at those units. It is the intent of this Committee 
that satisfying the requirements of the IHS's centralized 
credential system also satisfies the requirements of 
privileging for licensed professionals providing temporary 
medical services at each individual service unit.
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    \30\25 U.S.C. 1601 et seq.
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    Additional IHS reforms include requiring all IHS employees 
and contractors to undergo cultural competency training; 
improving IHS doctor recruitments by expanding the loan 
repayment program and existing recruitment tools; streamlining 
the volunteer credentialing process and reducing related 
paperwork burdens; providing transparency in reports from the 
Center for Medicare & Medicaid Services; requiring regular 
reporting from the IHS, the Government Accountability Office, 
and the HHS Office of Inspector General on patient care; and 
providing whistleblower retaliation protections for IHS 
employees.

            Section-by-Section Analysis of Major Provisions


              TITLE I--INDIAN HEALTH SERVICE IMPROVEMENTS

Section 101. Incentives for recruitment and retention

     Improves IHS' recruitment activities by 
permanently expanding IHS' authority to provide increased pay 
for certain medical providers and enables IHS to pay relocation 
costs for employees and provide housing vouchers for employees.

Sec. 102. Medical credentialing system

     Requires IHS to develop an agency-wide centralized 
credentialing system for licensed health professionals, which 
is to be developed and implemented no later than one year after 
the date of enactment.
     This system must be uniform throughout the agency 
and allow credentialed individuals to provide services 
throughout the IHS system.
     IHS must consult with tribes in developing the 
system.

Sec. 103. Liability protections for health professional volunteers at 
        Indian Health Service

     Deems health professionals who volunteer at IHS 
facilities employees of the Public Health Service.

Sec. 104. Clarification regarding eligibility for Indian Health Service 
        loan repayment program

     Expands the types of professionals eligible for 
the IHS student loan repayment program to include individuals 
with master's degrees in business administration with an 
emphasis in health care management, health administration, 
hospital administration, or public health.
     Requires program participants to work at IHS two 
years or longer, or four years or longer if working half-time.

Sec. 105. Improvements in hiring practices

     Allows IHS direct hire authority.
     Requires IHS to provide a notice and comment 
period to a tribe before appointing, hiring, transferring, or 
reassigning a Senior Executive Service employee or a manager.
     Requires IHS to seek waivers of Indian preference 
hiring when 15 percent or more of an IHS facility's health 
professional positions are not filled by a full-time IHS 
employee for six months or more, or if the only available 
applicant is a former IHS or tribal employee who was removed or 
demoted for performance or misconduct within the previous five 
years.

Sec. 106. Improved authorities of Secretary to improve accountability 
        of Senior Executives and employees of the Indian Health Service

     Expands IHS authority to reprimand, suspend, 
reassign, demote, or remove certain individuals from Senior 
Executive Service positions if it is determined that misconduct 
or performance warrants such action, and provides thorough due 
process for individuals subject to reprimand, suspension, 
reassignment, demotion, or removal.

Sec. 107. Tribal culture and history

     Requires IHS to develop a cultural training 
program that is mandatory for all IHS employees and IHS 
contractors.

Sec. 108. Staffing demonstration project

     Requires IHS to establish a demonstration project 
to determine whether increased staffing resources for certain 
facilities results in self-sustaining resources.
     The demonstration may operate as IHS deems 
appropriate, but each staffing position shall be for a period 
of no less than three fiscal years.

Sec. 109. Rule establishing tribal consultation policy

     Requires IHS to establish a tribal consultation 
policy.

Sec. 110. Treatment of certain hospitals

     Retroactively applies the provisions of a rule 
from the Centers for Medicare & Medicaid Services related to 
low-volume hospital payment adjustments.

                     TITLE II--EMPLOYEE PROTECTIONS

Sec. 201. Employee protections against retaliation

     Provides a process for mandatory reporting for 
witnesses of retaliation against a whistleblower, or a patient 
safety requirement, or similar misconduct.
     Allows IHS to remove employees who have retaliated 
against whistleblowers.
     Enhances protections for whistleblowers.

Sec. 202. Right of federal employees to petition Congress

     Reiterates the right of federal employees to 
petition Congress.
     Expands the federal government's ability to punish 
employees who interfere with another employee's right to 
petition Congress.
     Requires IHS to provide each IHS employee a 
memorandum reiterating his or her right to petition Congress.

Sec. 203. Fiscal accountability

     Provides that IHS may not provide raises or 
bonuses to certain high-ranking employees if it fails to submit 
the professional housing plan or staffing plan required by the 
bill.
     Requires IHS to spend unobligated and unspent 
amounts on patient care.
     Requires IHS to provide quarterly spending reports 
at each level of the agency to each tribe and Congress.

                           TITLE III--REPORTS

Sec. 302. Reports by the Secretary of Health and Human Services

     Requires IHS to develop and publish a professional 
housing plan that comports with recommendations of the 
Government Accountability Office (GAO).
     Requires IHS to develop and publish a staffing 
plan.
     Requires IHS to develop and publish a report on 
certain data under section 108 of the IHCIA.

Sec. 303. Reports by the Comptroller General

     Requires GAO to develop and submit to Congress a 
report regarding IHS housing needs.
     Requires GAO to develop and submit to Congress a 
report regarding IHS staffing needs.

Sec. 304. Inspector General reports

     Requires the HHS Inspector General to develop and 
submit to Congress and IHS a report on patient harm events 
occurring in the agency.

Sec. 304. Transparency in CMS surveys

     Requires CMS to conduct surveys of IHS facilities 
no less frequently than every two years and publish the results 
on the CMS website.

                     TITLE IV--TECHNICAL AMENDMENTS

Sec. 401. Technical amendments

     Replaces the term ``contract health service'' with 
``purchased/referred care'' throughout the IHCIA.

                            Committee Action

    H.R. 5874 was introduced on May 18, 2018, by Congresswoman 
Kristi L. Noem (R-SD). The bill was referred primarily to the 
Committee on Natural Resources, and in addition to the 
Committee on Energy and Commerce, the Committee on Ways and 
Means, and the Committee on Oversight and Government Reform. On 
June 13, 2018, the Committee on Natural Resources met to 
consider the bill. Congressman Paul A. Gosar (R-AZ) offered and 
withdrew amendment designated 114. No further amendments were 
offered, and the bill was ordered favorably reported to the 
House of Representatives by voice vote.

            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 Natural Resources' oversight findings and 
recommendations are reflected in the body of this report.

      Compliance With House Rule XIII and Congressional Budget Act

    1. Cost of Legislation and the Congressional Budget Act. 
With respect to the requirements of clause 3(c)(2) and (3) of 
rule XIII of the Rules of the House of Representatives and 
sections 308(a) and 402 of the Congressional Budget Act of 
1974, the Committee has received the following estimate for the 
bill from the Director of the Congressional Budget Office:

                                     U.S. Congress,
                               Congressional Budget Office,
                                     Washington, DC, July 23, 2018.
Hon. Rob Bishop,
Chairman, Committee on Natural Resources,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 5874, the 
Restoring Accountability in the Indian Health Service Act of 
2018.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Robert 
Stewart.
            Sincerely,
                                             Mark P. Hadley
                                        (For Keith Hall, Director.)
    Enclosure.

H.R. 5874--Restoring Accountability in the Indian Health Service Act of 
        2018

    Summary: H.R. 5874 would change personnel practices of the 
Indian Health Service (IHS) to facilitate the recruitment and 
retention of employees, clarify eligibility for the IHS loan 
repayment program, allow the Secretary of Health and Human 
Services (HHS) to appoint qualified candidates directly to 
vacant positions that are difficult to fill, and require the 
IHS to implement new methods of measuring the timeliness of 
care. CBO estimates that implementing H.R. 5874 would cost $115 
million over the 2019-2023 period, assuming appropriation of 
the necessary amounts.
    H.R. 5874 also would apply the same liability protections 
available to all medical professionals employed by the Public 
Health Service to medical professionals who volunteer their 
service at IHS. CBO estimates that this provision would 
increase direct spending by less than $500,000 over the 2019-
2023 period.
    Because the bill would affect direct spending or revenues, 
pay-as-you-go procedures apply.
    CBO estimates that enacting the legislation would not 
significantly increase net direct spending or on-budget 
deficits in any of the four consecutive 10-year periods 
beginning in 2029.
    H.R. 5874 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
    Estimated cost to the Federal Government: The estimated 
budgetary effect of H.R. 5874 is shown in the following table. 
The costs of this legislation fall primarily within budget 
function 550 (health).

----------------------------------------------------------------------------------------------------------------
                                                                   By fiscal year, in millions of dollars--
                                                            ----------------------------------------------------
                                                              2018   2019   2020   2021   2022   2023  2019-2023
----------------------------------------------------------------------------------------------------------------
                                 INCREASES IN SPENDING SUBJECT TO APPROPRIATION*
 
Incentives for Recruitment and Retention:
    Estimated Authorization Level..........................      0     17     18     19     20     21        95
    Estimated Outlays......................................      0     17     18     19     20     21        95
Medical Credentialing System:
    Estimated Authorization Level..........................      0      1      *      *      *      *         1
    Estimated Outlays......................................      0      1      *      *      *      *         1
Clarification Regarding Eligibility for the Indian Health
 Service Loan Repayment Program:
    Estimated Authorization Level..........................      0      *      1      1      2      2         7
    Estimated Outlays......................................      0      *      1      1      2      2         7
Improvements in Hiring Practices:
    Estimated Authorization Level..........................      0      1      1      1      1      1         5
    Estimated Outlays......................................      0      1      1      1      1      1         5
Tribal Culture and History:
    Estimated Authorization Level..........................      0      *      *      *      *      *         1
    Estimated Outlays......................................      0      *      *      *      *      *         1
Rule Establishing Tribal Consultation Policy:
    Estimated Authorization Level..........................      0      *      *      *      *      *         1
    Estimated Outlays......................................      0      *      *      *      *      *         1
Employee Protections Against Retaliation:
    Estimated Authorization Level..........................      0      *      *      *      *      *         2
    Estimated Outlays......................................      0      *      *      *      *      *         2
Fiscal Accountability:
    Estimated Authorization Level..........................      0      1      *      *      *      *         1
    Estimated Outlays......................................      0      1      *      *      *      *         1
Reports by the Comptroller General:
    Estimated Authorization Level..........................      0      *      *      *      *      0         1
    Estimated Outlays......................................      0      *      *      *      *      0         1
Transparency in CMS Surveys:
    Estimated Authorization Level..........................      0      *      *      *      *      *         2
    Estimated Outlays......................................      0      *      *      *      *      *         2
        Total Changes:
            Estimated Authorization Level..................      0     21     22     22     24     26       115
            Estimated Outlays..............................      0     21     22     22     24     26       115
----------------------------------------------------------------------------------------------------------------
Notes: * = less than $500,000; Components may not sum to totals because of rounding.
a. Enacting the legislation also would increase direct spending by less than $500,000 per year and over the 2019-
  2028 period.

    Basis of estimate: For this estimate, CBO assumes that H.R. 
5874 will be enacted near the end of fiscal year 2018 and that 
estimated amounts will be appropriated each year thereafter.

Spending subject to appropriation

    Assuming appropriation of the necessary amounts, CBO 
estimates that implementing H.R. 5874 would cost $115 million 
over the 2019-2023 period.
    Incentives for Recruitment and Retention. Section 101 of 
the bill would authorize the Secretary to pay all IHS employees 
with health care responsibilities according to pay scales used 
by the Department of Veterans Affairs (VA). Currently IHS uses 
that scale when compensating physicians and dentists but not 
nurses or pharmacists. The VA scale adjusts wages for the cost 
of living at the job location. CBO expects that with this new 
authority IHS would be more successful in recruiting and 
retaining employees, salaries would be more competitive across 
all of its service sites, and as a result, the number of nurses 
and pharmacists at IHS would increase gradually over time. 
Based on an analysis of data on the number of nurses and 
pharmacists employed by IHS and of the difference between the 
IHS and VA pay scales, CBO estimates that allowing IHS to 
compensate all health care employees at the VA pay scale would 
increase salaries for affected employees by an average of 
$11,000 to $14,000 annually (about 10 percent) and gradually 
would increase the number of nurses and pharmacists by 160 
(about 5 percent) at a cost of $95 million over the 2019-2023 
period.
    Medical Credentialing System. Section 102 would require the 
Secretary to establish a credentialing process for health care 
practitioners who volunteer their services at IHS facilities. 
IHS allows volunteers to donate both medical and non-medical 
services to patients of the agency. Based on information 
provided by IHS, CBO expects that the agency would acquire an 
existing commercial credentialing system at a cost of 
approximately $500,000. Employees in IHS headquarters, various 
area offices, and hundreds of IHS facilities would coordinate 
and implement the system. In total, CBO estimates that the 
combination of the system's acquisition and the additional 
personnel time involved in its operation would cost about $1 
million over the 2019-2023 period.
    Clarification Regarding Eligibility for the Indian Health 
Service Loan Repayment Program. Section 104 would allow 
individuals with business administration and health management 
degrees to qualify for a repayment program for student loans 
through IHS. Under current law, IHS repays the student loans of 
some employees who are health care professionals in exchange 
for commitments to work for IHS for at least two years. That 
loan repayment program costs about $28,000 per participating 
employee, on average. According to a 2016 HHS Office of the 
Inspector General (OIG) report, IHS has historically had 
difficulty recruiting and retaining health administrators. 
Providing loan repayments to management professionals could 
allow the IHS to be more successful in hiring additional 
management staff. However, many of the challenges to recruiting 
for IHS involve factors that are not related to financial 
compensation, such as the geographic isolation of many IHS 
facilities and a lack of nearby housing. CBO projects that 
permitting those with management and business degrees to 
receive loan repayments would gradually increase the number of 
loan recipients over time, reaching about 60 additional 
recipients by 2023. CBO estimates that this provision would 
cost $7 million over the 2019-2023 period.
    Improvements in Hiring Practices. Section 105 would allow 
the Secretary to appoint a candidate directly to a position at 
IHS without regard to standard civil service practices as long 
as the candidate meets the job description of the Office of 
Personnel Management (OPM). CBO expects that the Secretary 
would use this authority rarely, mostly in situations when a 
qualified candidate is identified for a difficult-to-fill 
vacancy in a position of critical need. CBO estimates that 
there would be a small decrease in the roughly 1,500 currently 
unfilled vacancies at IHS, principally because direct 
Secretarial appointment would allow some candidates to start 
more quickly than they otherwise would. CBO estimates this 
provision would increase the number of employees at the agency 
by the equivalent of about 7 annually at a cost of $5 million 
over the 2019-2023 period.
    Tribal Culture and History. Section 107 would require IHS 
to institute cultural competency training for any employee or 
contractor who has regular direct patient access. CBO expects 
that requirement to apply to most medical personnel and some 
administrative personnel. IHS would provide training annually, 
and completion would be a condition of employment with IHS. The 
agency uses an online system for conducting agency-wide 
training, including some cultural competency training, but the 
new requirement would involve more customization to account for 
specific tribes within the IHS territories. Based on 
information provided by IHS, CBO projects that developing the 
additional training would require the equivalent of about 3 
full-time employees, and the annual administration of the 
training would require the equivalent of about one full-time 
employee at an average cost of $124,000 per employee. In total, 
CBO estimates that this provision would cost about $1 million 
over the 2019-2023 period.
    Rule Establishing Tribal Consultation Policy. Section 109 
would require the Secretary, within one year, to establish a 
rule to update and replace the current tribal consultation 
process. IHS currently consults with tribes through national, 
regional and local meetings between IHS and tribal officials 
regarding a variety of topics, such as improving patient care 
delivery, setting priorities for diabetes and behavioral health 
care, and developing information systems. The new policy would 
identify circumstances when the Secretary should notify tribes, 
describe how they should be notified, and define what actions 
constitute meaningful consultation.
    CBO projects that the equivalent of three full-time 
employees would be required for the rulemaking process, both 
from the IHS headquarters and the IHS area offices. Once the 
rule is promulgated, CBO expects the new rule would require 
more frequent consultation with the tribes than under current 
law, resulting in the equivalent of 1 full-time employee per 
year in additional staff time at an average annual cost of 
$124,000. In total, CBO estimates that this provision would 
cost about $1 million over the 2019-2023 period.
    Employee Protection Against Retaliation. Section 201 would 
require the Secretary to designate an agency-level employee to 
reach out to all employees of IHS about federal and 
departmental protections for reporting retaliation against 
whistleblowers and about the duty of employees of IHS to report 
violations of patient safety requirements or other similar 
misconduct. In addition, the designated employee would receive 
reports from employees of IHS who witness misconduct and, 
within three days of receiving such a report, provide the 
report to the Secretary, who must formally review it and 
provide a copy to the HHS OIG. Finally, the Secretary could 
take other actions to protect whistleblowers, including 
identifying appropriate IHS employees to complete the Office of 
Special Counsel's Whistleblower Certification Program.
    CBO projects that the designated employee would spend the 
equivalent of half a full-time employee on their new 
responsibilities initially and then the equivalent of one-
quarter of a full-time employee thereafter. In addition, CBO 
expects that implementing this section would lead to a small 
increase in complaints from IHS employees, and therefore to a 
small increase in OIG investigations. CBO also expects that the 
Secretary would designate additional employees within IHS area 
offices and important health care delivery sites to complete 
the Office of Special Counsel's Whistleblower Certification 
Program each year. Taken together, CBO estimates that this 
provision would cost $2 million over the 2019-2023 period.
    Fiscal Accountability. Section 203 would require the 
Secretary to issue quarterly reports to all Indian tribes and 
to the Congress describing all authorizations, expenditures, 
outlays, transfers, financial reprogramming, and obligations at 
each level of the IHS. In addition, the section would require 
the Secretary to issue annual reports to all Indian tribes and 
the Congress regarding the safety, billing, certification, 
credential, and compliance status of each IHS facility. Should 
the status of any facility change, the Secretary would issue 
updates describing the change. Based on information from IHS, 
CBO expects that the reports would require a significant 
investment of staff time to compile the information into report 
form and to write accompanying explanatory text. The greatest 
level of effort would occur in 2019 as IHS develops the two 
reports and then be somewhat less thereafter for annual updates 
to the reports. CBO projects that section 203 would require the 
equivalent of five full-time employees in 2019, the equivalent 
of three full-time employees in 2020, and then the equivalent 
of one full-time employee in subsequent years. In total, CBO 
estimates that the provision would cost about $1 million over 
the 2019-2023 period.
    Reports by the Comptroller General. Section 303 would 
require the Government Accountability Office (GAO) to submit 
three reports related to housing needs for IHS employees, 
staffing needs for the agency, and whether IHS has done enough 
to prevent retaliation against whistleblowers. Based on 
historical spending for similar activities, CBO estimates that 
this provision would cost about $1 million over the 2019-2023 
period.
    Transparency in CMS Surveys. Section 305 would require the 
Administrator of the Centers for Medicare and Medicaid Services 
(CMS) to modify current practice with respect to inspecting IHS 
facilities. Specifically, the bill would require the 
Administrator to inspect IHS nursing facilities and hospitals 
at least once every two years. Under current law, CMS surveys 
hospitals every three years and nursing facilities annually; 
H.R. 5874 would thus increase the frequency of hospital 
inspections but would reduce the frequency of nursing facility 
inspections.
    Survey activities are conducted in one of two ways: CMS 
contracts with state agencies, or facilities contract with 
accrediting organizations (AOs), including the Joint Commission 
on the Accreditation of Health Care Organizations. State 
agencies conduct nursing home surveys; hospitals may use either 
state agencies or AOs. Facilities that contract with AOs pay 
for their inspection and survey activities. State agencies 
inspect those facilities that do not contract with AOs, and CMS 
funding supports state activities in this area. The majority of 
IHS hospitals contract with AOs. There are currently no IHS 
nursing facilities.
    Given the relatively small number of IHS hospitals that 
would be surveyed by state agencies using federal funds, CBO 
estimates that this provision increase spending by about $2 
million over the 2019-2023 period.
    Other Provisions. Other provisions in H.R. 5874 would each 
cost less than $500,000 over the 2019-2023 period, assuming 
appropriation actions consistent with the bill.
     Section 106 would allow the Secretary to remove or 
demote IHS employees without adhering to certain civil service 
rules that normally affect such actions for federal employees.
     Section 108 would require the Secretary to 
establish a demonstration project that authorizes IHS to 
provide IHS service sites with additional staffing resources 
with the goal that the sites become self-sustaining through 
increasing care to patients with Medicare or Medicaid.
     Section 110 would apply the Medicare low-volume 
payment adjustment applicable to certain hospitals operated by 
the IHS or tribes to patient discharges occurring in fiscal 
year 2011 and subsequent fiscal years.
     Section 202 would subject any federal employees 
who interferes with the right of other federal employees to 
petition the Congress to adverse actions under civil service 
rules.
     Section 302 would require the Secretary to develop 
plans and submit reports to the Congress that comport with 
GAO's recommendations for improving professional housing, 
workforce planning, and timeliness of care.
     Section 304 would require the HHS Office of the 
Inspector General to submit two reports to Congress on issues 
related to patient harm events at IHS service units and IHS 
reporting systems.

Direct spending

    Section 103 of H.R. 5874 would deem health professionals 
who volunteer with the IHS to be employees of the U.S. Public 
Health Service (PHS), similar to other medical professionals at 
IHS. Under current law, the Secretary of HHS must estimate 
legal expenses (court judgements and settlements) that may be 
paid because of claims against employees of the PHS (typically 
for malpractice). The estimated amounts are transferred to the 
Judgement Fund in the U.S. Treasury, which is a fund that pays 
legal claims against the federal government.
    Deeming volunteers to be employees of the PHS would grant 
those employees protection from malpractice claims against them 
and would require the Secretary to include such volunteers in 
the calculation of potential claims against PHS employees. 
Based on information provided by IHS, the agency expects that 
shielding volunteers from personal liability from malpractice 
claims would lead to an increase in medical professionals 
willing to volunteer at the IHS, leading to a proportional 
increase in Judgement Fund payments on behalf of IHS employees. 
The Judgement Fund is funded by a permanent indefinite 
appropriation, and outlays from the fund are considered direct 
spending. According to information from the Treasury 
Department, about $9.5 million has been paid annually over the 
past 5 years from the Judgement Fund, on average, for 
malpractice claims against IHS employees. Based on the small 
increase in full-time equivalent employees because of this 
section and based on the average rate at which IHS employees 
generate payments from the Judgement Fund, CBO estimates this 
provision would increase direct spending by less than $500,000 
over the 2019-2028 period.
    Pay-As-You-Go considerations: The Statutory Pay-As-You-Go 
Act of 2010 establishes budget-reporting and enforcement 
procedures for legislation affecting direct spending or 
revenues. The net changes in outlays that are subject to those 
pay-as-you-go procedures would be insignificant.
    Increase in long-term direct spending and deficits: CBO 
estimates that enacting the legislation would not significantly 
increase net direct spending or on-budget deficits in any of 
the four consecutive 10-year periods beginning in 2029.
    Intergovernmental and private-sector impact: CBO has 
determined that H.R. 5874 contains no intergovernmental or 
private-sector mandates as defined in UMRA.
    Estimate prepared by: Federal Costs: Robert Stewart--IHS, 
Lara Robillard--Medicare; Mandates: Zachary Byrum.
    Estimate approved by: Leo Lex, Deputy Assistant Director 
for Budget Analysis.
    2. 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 improve the recruitment and retention of 
employees in the Indian Health Service, restore accountability 
in the Indian Health Service, and improve health services.

                           Earmark Statement

    This bill does not contain any Congressional earmarks, 
limited tax benefits, or limited tariff benefits as defined 
under clause 9(e), 9(f), and 9(g) of rule XXI of the Rules of 
the House of Representatives.

                    Compliance With Public Law 104-4

    This bill contains no unfunded mandates.

                       Compliance With H. Res. 5

    Directed Rule Making. This bill does not contain any 
directed rule makings.
    Duplication of Existing Programs. This bill provides 
reforms for programs that were identified as areas of potential 
duplication, overlap, and fragmentation, which if effectively 
addressed, could provide financial and other benefits. Such 
program was included in a report from the Government 
Accountability Office to Congress pursuant to section 21 of 
Public Law 111-139 or identified in the most recent Catalog of 
Federal Domestic Assistance published pursuant to the Federal 
Program Information Act (Public Law 95-220, as amended by 
Public Law 98-169) as relating to other programs.

                Preemption of State, Local or Tribal Law

    This bill is not intended to preempt any State, local or 
tribal law.

         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, and existing law in which no 
change is proposed is shown in roman):

                   INDIAN HEALTH CARE IMPROVEMENT ACT



           *       *       *       *       *       *       *
                              definitions

  Sec. 4. In this Act:
          (1) Area office.--The term ``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.
          (2) Behavioral health.--
                  (A) In general.--The term ``behavioral 
                health'' means the blending of substance 
                (alcohol, drugs, inhalants, and tobacco) abuse 
                and mental health disorders prevention and 
                treatment for the purpose of providing 
                comprehensive services.
                  (B) Inclusions.--The term ``behavioral 
                health'' includes the joint development of 
                substance abuse and mental health treatment 
                planning and coordinated case management using 
                a multidisciplinary approach.
          (3) California indian.--The term ``California 
        Indian'' means any Indian who is eligible for health 
        services provided by the Service pursuant to section 
        809.
          (4) Community college.--The term ``community 
        college'' means--
                  (A) a tribal college or university; or
                  (B) a junior or community college.
          (5) Contract health service.--The term ``[contract 
        health service] purchased/referred care'' means any 
        health service that is--
                  (A) delivered based on a referral by, or at 
                the expense of, an Indian health program; and
                  (B) provided by a public or private medical 
                provider or hospital that is not a provider or 
                hospital of the Indian health program.
          (6) Department.--The term ``Department'', unless 
        otherwise designated, means the Department of Health 
        and Human Services.
          (7) Disease prevention.--
                  (A) In general.--The term ``disease 
                prevention'' means any activity for--
                          (i) the reduction, limitation, and 
                        prevention of--
                                  (I) disease; and
                                  (II) complications of 
                                disease; and
                          (ii) the reduction of consequences of 
                        disease.
                  (B) Inclusions.--The term ``disease 
                prevention'' includes an activity for--
                          (i) controlling--
                                  (I) the development of 
                                diabetes;
                                  (II) high blood pressure;
                                  (III) infectious agents;
                                  (IV) injuries;
                                  (V) occupational hazards and 
                                disabilities;
                                  (VI) sexually transmittable 
                                diseases; or
                                  (VII) toxic agents; or
                          (ii) providing--
                                  (I) fluoridation of water; or
                                  (II) immunizations.
          (8) FAE.--The term ``FAE'' means fetal alcohol 
        effect.
          (9) 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 mental retardation, 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.
          (10) Health profession.--The term ``Health 
        profession'' means allopathic medicine, family 
        medicine, internal medicine, pediatrics, geriatric 
        medicine, obstetrics and gynecology, podiatric 
        medicine, nursing, public health nursing, dentistry, 
        psychiatry, osteopathy, optometry, pharmacy, 
        psychology, public health, social work, marriage and 
        family therapy, chiropractic medicine, environmental 
        health and engineering, an allied health profession, or 
        any other health profession.
          (11) Health promotion.--The term ``health promotion'' 
        means any activity for--
                  (A) fostering social, economic, 
                environmental, and personal factors conducive 
                to health, including raising public awareness 
                regarding health matters and enabling 
                individuals to cope with health problems by 
                increasing knowledge and providing valid 
                information;
                  (B) encouraging adequate and appropriate 
                diet, exercise, and sleep;
                  (C) promoting education and work in 
                accordance with physical and mental capacity;
                  (D) making available safe water and sanitary 
                facilities;
                  (E) improving the physical, economic, 
                cultural, psychological, and social 
                environment;
                  (F) promoting culturally competent care; and
                  (G) providing adequate and appropriate 
                programs, including programs for--
                          (i) abuse prevention (mental and 
                        physical);
                          (ii) community health;
                          (iii) community safety;
                          (iv) consumer health education;
                          (v) diet and nutrition;
                          (vi) immunization and other methods 
                        of prevention of communicable diseases, 
                        including HIV/AIDS;
                          (vii) environmental health;
                          (viii) exercise and physical fitness;
                          (ix) avoidance of fetal alcohol 
                        spectrum disorders;
                          (x) first aid and CPR education;
                          (xi) human growth and development;
                          (xii) injury prevention and personal 
                        safety;
                          (xiii) behavioral health;
                          (xiv) monitoring of disease 
                        indicators between health care provider 
                        visits through appropriate means, 
                        including Internet-based health care 
                        management systems;
                          (xv) personal health and wellness 
                        practices;
                          (xvi) personal capacity building;
                          (xvii) prenatal, pregnancy, and 
                        infant care;
                          (xviii) psychological well-being;
                          (xix) reproductive health and family 
                        planning;
                          (xx) safe and adequate water;
                          (xxi) healthy work environments;
                          (xxii) elimination, reduction, and 
                        prevention of contaminants that create 
                        unhealthy household conditions 
                        (including mold and other allergens);
                          (xxiii) stress control;
                          (xxiv) substance abuse;
                          (xxv) sanitary facilities;
                          (xxvi) sudden infant death syndrome 
                        prevention;
                          (xxvii) tobacco use cessation and 
                        reduction;
                          (xxviii) violence prevention; and
                          (xxix) such other activities 
                        identified by the Service, a tribal 
                        health program, or an urban Indian 
                        organization to promote achievement of 
                        any of the objectives referred to in 
                        section 3(2).
          (12) Indian health program.--The term ``Indian health 
        program'' means--
                  (A) any health program administered directly 
                by the Service;
                  (B) any tribal health program; and
                  (C) any Indian tribe or tribal organization 
                to which the Secretary provides funding 
                pursuant to section 23 of the Act of June 25, 
                1910 (25 U.S.C. 47) (commonly known as the 
                ``Buy Indian Act'').
          (13) Indians or indian.--The term ``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 (A), 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 (B) is 
        an Eskimo or Aleut or other Alaska Native, or (C) is 
        considered by the Secretary of the Interior to be an 
        Indian for any purpose, or (D) is determined to be an 
        Indian under regulations promulgated by the Secretary.
          (14) Indian tribe.--The term ``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.
          (15) Junior or community college.--The term ``junior 
        or community college' has the meaning given the term in 
        section 312(e) of the Higher Education Act of 1965 (20 
        U.S.C. 1058(e)).
          (16) Reservation.--
                  (A) In general.--The term ``reservation'' 
                means a reservation, Pueblo, or colony of any 
                Indian tribe.
                  (B) Inclusions.--The term ``reservation'' 
                includes--
                          (i) former reservations in Oklahoma;
                          (ii) Indian allotments; and
                          (iii) Alaska Native Regions 
                        established pursuant to the Alaska 
                        Native Claims Settlement Act (43 U.S.C. 
                        1601 et seq.).
          (17) Secretary.--The term ``Secretary'', unless 
        otherwise designated, means the Secretary of Health and 
        Human Services.
          (18) Service.--The term``Service'' means the Indian 
        Health Service.
          (19) Service area.--The term ``Service area'' means 
        the geographical area served by each area office.
          (20) Service unit.--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) Substance abuse.--The term ``Substance abuse'' 
        includes inhalant abuse.
          (22) Telehealth.--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)).
          (23) Telemedicine.--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.
          (24) Tribal college or university.--The term ``tribal 
        college or university'' has the meaning given the term 
        in section 316(b) of the Higher Education Act of 1965 
        (20 U.S.C. 1059c(b)).
          (25) Tribal health program.--The term ``tribal health 
        program'' means an Indian tribe or tribal organization 
        that operates any health program, service, function, 
        activity, or facility funded, in whole or part, by the 
        Service through, or provided for in, a contract or 
        compact with the Service under the Indian Self-
        Determination and Education Assistance Act (25 U.S.C. 
        450 et seq.).
          (26) Tribal organization.--The term ``tribal 
        organization'' has the meaning given the term in 
        section 4 of the Indian Self-Determination and 
        Education Assistance Act (25 U.S.C. 450b).
          (27) Urban center.--The term ``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.
          (28) Urban indian.--The term ``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.
          (29) Urban indian organization.--The term ``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).

TITLE I--INDIAN HEALTH MANPOWER

           *       *       *       *       *       *       *


              INDIAN HEALTH SERVICE LOAN REPAYMENT PROGRAM

  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;]
                  (B) have--
                          (i)(I) a degree in a health 
                        profession; and
                          (II) a license to practice a health 
                        profession in a State; or
                          (ii)(I) a master's degree in business 
                        administration with an emphasis in 
                        health care management (as defined by 
                        the Secretary), health administration, 
                        hospital administration, or public 
                        health; and
                          (II) a license or certification to 
                        practice in the field of business 
                        administration, health administration, 
                        hospital administration, or public 
                        health in a State, if the Secretary 
                        determines such license or 
                        certification necessary for the Indian 
                        health program to which the individual 
                        will be assigned;
                          (iii) maintain credentials as 
                        determined by the system described in 
                        section 102; and
                          (iv) participate in the training 
                        described in section 107;
          (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;]
                          (iii) to serve for a time period 
                        (referred to in this section as the 
                        ``period of obligated service'') equal 
                        to--
                                  (I) 2 years or such longer 
                                period as the individual may 
                                agree to serve in the full-time 
                                practice of such individual's 
                                profession in an Indian health 
                                program to which the individual 
                                may be assigned by the 
                                Secretary; or
                                  (II) 4 years or such longer 
                                period as the individual may 
                                agree to serve in the half-time 
                                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 of the 
individual (or both), which loans were made for--
          (A) tuition expenses;
          (B) all other reasonable educational expenses, 
        including fees, books, and laboratory expenses, 
        incurred by the individual; and
          (C) reasonable living expenses as determined by the 
        Secretary.
  (2)(A) [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 the case of an individual who contracts to serve a period of 
obligated service under subsection (f)(1)(B)(iii)(I), for each 
year of such obligated service, 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 (42 U.S.C. 254l-
1(g)(2)(A))) on behalf of the individual for loans described in 
paragraph (1). In the case of an individual who contracts to 
serve a period of obligated service under subsection 
(f)(1)(B)(iii)(II), for each year of such obligated service, 
the Secretary may pay up to $17,500 on behalf of the individual 
for loans described in paragraph (1) [In making a 
determination]
          (B) In making a determination under this paragraph  
        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)] (C) 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 the 
Department of Health and Human Services.
  (i) The Secretary shall conduct recruiting programs for the 
Loan Repayment Program and other health professional programs 
of the Service at educational institutions training health 
professionals or specialists identified in subsection (a).
  (j) 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) The Secretary, in assigning individuals to serve in 
Indian health programs pursuant to contracts entered into under 
this section, shall--
          (1) ensure that the staffing needs of Indian health 
        programs administered by an Indian tribe or tribal or 
        health organization 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 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)(1) An individual who has entered into a written contract 
with the Secretary under this section and who--
          (A) is enrolled in the final year of a course of 
        study and who--
                  (i) fails to maintain an acceptable level of 
                academic standing in the educational 
                institution in which he 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, fails 
        to complete such training program, and does not receive 
        a waiver from the Secretary under subsection 
        (b)(1)(B)(ii),
shall be liable, in lieu of any service obligation arising 
under such contract, to the United States for the amount which 
has been paid on such individual's behalf under the contract.
  (2) If, for any reason not specified in paragraph (1), an 
individual breaches his written contract under this section by 
failing either to begin, or complete, such individual's period 
of obligated service in accordance with subsection (f), the 
United States shall be entitled to recover from such individual 
an amount to be determined in accordance with the following 
formula:


 
A=3Z(t-s/t)

in which--
          (A) ``A'' is the amount the United States is entitled 
        to recover;
          (B) ``Z'' is the sum of the amounts paid under this 
        section to, or on behalf of, the individual and the 
        interest on such amounts which would be payable if, at 
        the time the amounts were paid, they were loans bearing 
        interest at the maximum legal prevailing rate, as 
        determined by the Treasurer of the United States;
          (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.
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.
  (3)(A) 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.
  (B) If damages described in subparagraph (A) are delinquent 
for 3 months, the Secretary shall, for the purpose of 
recovering such damages--
          (i) utilize collection agencies contracted with by 
        the Administrator of the General Services 
        Administration; or
          (ii) enter into contracts for the recovery of such 
        damages with collection agencies selected by the 
        Secretary.
  (C) 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)(1) Any obligation of an individual under the Loan 
Repayment Program for service or payment of damages shall be 
canceled upon the death of the individual.
  (2) 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.
  (3) 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) 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) The Secretary shall submit to the President, for 
inclusion in each report required to be submitted to the 
Congress under section 801, a report concerning the previous 
fiscal year which sets forth--
          (1) the health professional positions maintained by 
        the Service or by tribal or 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 
        (f) 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 scholarship grants that are 
        provided under section 104 with respect to each health 
        profession;
          (6) the amount of scholarship grants provided under 
        section 104, in total and by health profession;
          (7) the number of providers of health care that will 
        be needed by Indian health programs, by location and 
        profession, during the three fiscal years beginning 
        after the date the report is filed; and
          (8) the measures the Secretary plans to take to fill 
        the health professional positions maintained by the 
        Service or by tribes or tribal or Indian organizations 
        for which recruitment or retention is difficult.

           *       *       *       *       *       *       *


                       TRIBAL CULTURE AND HISTORY

  Sec. 113. (a) The Secretary, acting through the Service, 
shall establish [a program] an annual mandatory training 
program under which [appropriate employees of the Service] 
employees of the Service, locum tenens medical providers, 
healthcare volunteers, and other contracted employees who work 
at Service hospitals or other Service units and whose 
employment requires regular direct patient access who serve 
particular Indian tribes shall receive educational instruction 
in the history and culture of such tribes and in the history of 
the Service.
  (b) To the extent feasible, the program established under 
subsection (a) shall--
          (1) be carried out through tribally controlled 
        colleges or universities (within the meaning of section 
        2(a)(4) of the Tribally Controlled Colleges and 
        Universities Act of 1978) and tribally controlled 
        postsecondary vocational institutions (as defined in 
        section 390(2) of the Tribally Controlled Vocational 
        Institutions Support Act of 1990 (20 U.S.C. 2397h(2)),
          (2) be developed in consultation with the affected 
        tribal government, and
          (3) include instruction in Native American studies.
  (c) Notwithstanding any other provision of law, beginning 
with the year of the date of enactment of the Restoring 
Accountability in the Indian Health Service Act of 2018, each 
employee or provider described in subsection (a) who enters 
into a contract with the Service on or after the date of such 
implementation shall, as a condition of employment, annually 
participate in and complete such training program. For purposes 
of the preceding sentence, participation in such training 
program may not be considered complete for the year involved 
until the individual satisfies each requirement, including 
testing, if applicable, of the training program for such year, 
as specified by the Secretary.

           *       *       *       *       *       *       *


SEC. 125. INCENTIVES FOR RECRUITMENT AND RETENTION.

  (a) Parity in IHS Health Care Workforce Personnel and Pay 
System.--The Secretary shall establish a personnel and pay 
system for physicians, dentists, nurses, and other health care 
professionals employed by the Service that provides a personnel 
and pay system that, to the maximum extent practicable, is 
comparable to the pay provided to physicians, dentists, nurses, 
and other health care professionals, respectively, under 
subchapters III and IV of chapter 74 of title 38, United States 
Code.
  (b) Relocation Costs.--The Secretary may provide to an 
employee of the Service reimbursement for any relocation costs 
the employee incurs if--
          (1) the employee relocates to a Service area 
        experiencing a high level of need for employees, as 
        determined by the Secretary; and
          (2) the employee is filling a position that would 
        otherwise be difficult to fill, as determined by the 
        Secretary, in the absence of an incentive.
  (c) Housing Vouchers.--
          (1) In general.--Subject to paragraph (2), not later 
        than 1 year after the date of enactment of the 
        Restoring Accountability in the Indian Health Service 
        Act of 2018, the Secretary may establish a program to 
        provide tenant-based rental assistance to an employee 
        of the Service who--
                  (A) agrees to serve for not less than 1 year 
                at a Service unit designated by the 
                Administrator of the Health Resources and 
                Services Administration as a health 
                professional shortage area, as defined in 
                section 332(a) of the Public Health Service Act 
                (42 U.S.C. 254e(a)), with the greatest staffing 
                need; and
                  (B) is a critical employee, as determined by 
                the Secretary.
          (2) Sunset.--Any program established by the Secretary 
        under paragraph (1) shall terminate on the date that is 
        3 years after the date on which any such program is 
        established.
  (d) Administration.--
          (1) OPM guidelines.--The Secretary shall carry out 
        subsection (b) in accordance with any guidelines of the 
        Office of Personnel Management relating to section 572 
        of title 5, Code of Federal Regulations (as in effect 
        on the date of enactment of the Restoring 
        Accountability in the Indian Health Service Act of 
        2018).
          (2) Service agreements.--The Secretary may only 
        provide reimbursement for any relocation costs under 
        subsection (b) or any other benefit under subsection 
        (c) to--
                  (A) a full-time employee who agrees to serve 
                for not less than 1 year in the Service, 
                beginning on the date of the agreement; or
                  (B) a part-time employee who agrees to serve 
                for not less than 2 years in the service 
                beginning on the date of the agreement.

SEC. 126. MEDICAL CREDENTIALING SYSTEM.

  (a) In General.--
          (1) Development and implementation timeline.--By not 
        later than 1 year after the date of enactment of the 
        Restoring Accountability in the Indian Health Service 
        Act of 2018, the Secretary, acting through the Service 
        and in accordance with the requirements described in 
        subsection (b), shall develop and implement a Service-
        wide centralized electronic credentialing system 
        (referred to in this section as the ``credentialing 
        system'') to credential licensed health professionals 
        who seek to provide health care services at any Service 
        unit, including physicians, nurses and physicians 
        assistants.
          (2) Implementation.--In implementing the 
        credentialing system, the Secretary--
                  (A) shall not require re-credentialing of 
                licensed health professionals who were 
                credentialed using existing Service policy 
                prior to the date of enactment of the Restoring 
                Accountability in the Indian Health Service Act 
                of 2018; and
                  (B) shall--
                          (i) use the credentialing system for 
                        all new applications of licensed health 
                        professionals and the migration of 
                        credentials data that existed prior to 
                        implementation into the system;
                          (ii) maintain the established 
                        timeline for re-credentialing of 
                        licensed health professionals who were 
                        credentialed prior to implementation, 
                        as defined by Service policy; and
                          (iii) review credentials for all 
                        professionals in the system, based on 
                        updated policies, on a not less than 
                        yearly basis. Licensed health 
                        professionals whose credentials would 
                        not have been approved under the 
                        updated policies shall have 90 days to 
                        meet the new requirements.
  (b) Requirements.--In developing the credentialing system 
under subsection (a), the Secretary shall ensure the following:
          (1) Credentialing procedures shall be uniform and 
        integrated throughout the Service.
          (2) With respect to each licensed health professional 
        who successfully completes the credentialing procedures 
        of the credentialing system, the Secretary may 
        authorize each such professional to provide health care 
        services at any Service unit.
          (3) Credentialing procedures shall include 
        verification of licensure, education, employment 
        history, and criminal background checks and history.
  (c) Consultation.--In developing the credentialing system 
under subsection (a), the Secretary shall consult with Indian 
Tribes and may also consult with any public or private 
association of medical providers, any government agency, or 
other relevant expert, as determined by the Secretary.
  (d) Application.--A licensed health care professional may not 
provide health care services at any Service unit, unless such 
professional successfully completes the credentialing 
procedures of the credentialing system developed under 
subsection (a).
  (e) Regulations.--The Secretary may prescribe such 
regulations as may be necessary to carry out the provisions of 
this section.
  (f) Rule of Construction.--Nothing in this section may be 
construed--
          (1) to negatively impact the right of an Indian Tribe 
        to enter into a compact or contract under the Indian 
        Self-Determination and Education Assistance Act (25 
        U.S.C. 5304 et seq.); and
          (2) to apply to such a compact or contract unless 
        expressly agreed to by the Indian Tribe.

                       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] purchased/referred 
        care 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.
                  (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 health care 
                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, including 
                data collection and evaluation, demonstration 
                projects, training, and capacity building.
                  (H) Home health care.
                  (I) Community health representatives.
                  (J) Maintenance and improvement.
  (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 
                sections 3(1) and 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 enactment of the Indian Health Care Improvement 
Reauthorization and Extension Act of 2009, 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''.

           *       *       *       *       *       *       *


       california contract health services demonstration program

  Sec. 211. (a) The Secretary shall establish a demonstration 
program to evaluate the use of a contract care intermediary to 
improve the accessibility of health services to California 
Indians.
  (b)(1) In establishing such program, the Secretary shall 
enter into an agreement with the California Rural Indian Health 
Board to reimburse the Board for costs (including reasonable 
administrative costs) incurred, during the period of the 
demonstration program, in providing medical treatment under 
contract to California Indians described in section 809(b) 
throughout the California [contract health services] purchased/
referred care delivery area described in section 810 with 
respect to high-cost contract care cases.
  (2) Not more than 5 percent of the amounts provided to the 
Board under this section for any fiscal year may be for 
reimbursement for administrative expenses incurred by the Board 
during such fiscal year.
  (3) No payment may be made for treatment provided under the 
demonstration program to the extent payment may be made for 
such treatment under the Catastrophic Health Emergency Fund 
described in section 202 or from amounts appropriated or 
otherwise made available to the California [contract health 
service] purchased/referred care delivery area for a fiscal 
year.
  (c) There is hereby established an advisory board which shall 
advise the California Rural Indian Health Board in carrying out 
the demonstration pursuant to this section. The advisory board 
shall be composed of representatives, selected by the 
California Rural Indian Health Board, from not less than 8 
tribal health programs serving California Indians covered under 
such demonstration, at least one half of whom are not 
affiliated with the California Rural Indian Health Board.
  (d) The demonstration program described in this section shall 
begin on January 1, 1993, and shall terminate on September 30, 
1997.
  (e) Not later than July 1, 1998, the California Rural Indian 
Health Board shall submit to the Secretary a report on the 
demonstration program carried out under this section, including 
a statement of its findings regarding the impact of using a 
contract care intermediary on--
          (1) access to needed health services;
          (2) waiting periods for receiving such services; and
          (3) the efficient management of high-cost contract 
        care cases.
  (f) For the purposes of this section, the term ``high-cost 
contract care cases'' means those cases in which the cost of 
the medical treatment provided to an individual--
          (1) would otherwise be eligible for reimbursement 
        from the Catastrophic Health Emergency Fund established 
        under section 202, except that the cost of such 
        treatment does not meet the threshold cost requirement 
        established pursuant to section 202(b)(2); and
          (2) exceeds $1,000.

           *       *       *       *       *       *       *


                 contract health services payment study

  Sec. 219. (a) The Secretary, acting through the Service and 
in consultation with representatives of Indian tribes and 
tribal organizations operating contract health care programs 
under the Indian Self-Determination Act (25 U.S.C. 450f et 
seq.) or under self-governance compacts, Service personnel, 
private [contract health services] purchased/referred care 
providers, the Indian Health Service Fiscal Intermediary, and 
other appropriate experts, shall conduct a study--
          (1) to assess and identify administrative barriers 
        that hinder the timely payment for services delivered 
        by private [contract health services] purchased/
        referred care providers to individual Indians by the 
        Service and the Indian Health Service Fiscal 
        Intermediary;
          (2) to assess and identify the impact of such delayed 
        payments upon the personal credit histories of 
        individual Indians who have been treated by such 
        providers; and
          (3) to determine the most efficient and effective 
        means of improving the Service's [contract health 
        services] purchased/referred care payment system and 
        ensuring the development of appropriate consumer 
        protection policies to protect individual Indians who 
        receive authorized services from private [contract 
        health services] purchased/referred care providers from 
        billing and collection practices, including the 
        development of materials and programs explaining 
        patients' rights and responsibilities.
  (b) The study required by subsection (a) shall--
          (1) assess the impact of the existing [contract 
        health services] purchased/referred care regulations 
        and policies upon the ability of the Service and the 
        Indian Health Service Fiscal Intermediary to process, 
        on a timely and efficient basis, the payment of bills 
        submitted by private [contract health services] 
        purchased/referred care providers;
          (2) assess the financial and any other burdens 
        imposed upon individual Indians and private [contract 
        health services] purchased/referred care providers by 
        delayed payments;
          (3) survey the policies and practices of collection 
        agencies used by [contract health services] purchased/
        referred care providers to collect payments for 
        services rendered to individual Indians;
          (4) identify appropriate changes in Federal policies, 
        administrative procedures, and regulations, to 
        eliminate the problems experienced by private [contract 
        health services] purchased/referred care providers and 
        individual Indians as a result of delayed payments; and
          (5) compare the Service's payment processing 
        requirements with private insurance claims processing 
        requirements to evaluate the systemic differences or 
        similarities employed by the Service and private 
        insurers.
  (c) Not later than 12 months after the date of the enactment 
of this section, the Secretary shall transmit to the Congress a 
report that includes--
          (1) a detailed description of the study conducted 
        pursuant to this section; and
          (2) a discussion of the findings and conclusions of 
        such study.

           *       *       *       *       *       *       *


SEC. 226. CONTRACT HEALTH SERVICE ADMINISTRATION AND DISBURSEMENT 
                    FORMULA.

  (a) Submission of Report.--As soon as practicable after the 
date of enactment of the Indian Health Care Improvement 
Reauthorization and Extension Act of 2009, the Comptroller 
General of the United States shall submit to the Secretary, the 
Committee on Indian Affairs of the Senate, and the Committee on 
Natural Resources of the House of Representatives, and make 
available to each Indian tribe, a report describing the results 
of the study of the Comptroller General regarding the funding 
of the [contract health service] purchased/referred care 
program (including historic funding levels and a recommendation 
of the funding level needed for the program) and the 
administration of the [contract health service] purchased/
referred care program (including the distribution of funds 
pursuant to the program), as requested by Congress in March 
2009, or pursuant to section 830.
  (b) Consultation With Tribes.--On receipt of the report under 
subsection (a), the Secretary shall consult with Indian tribes 
regarding the [contract health service] purchased/referred care 
program, including the distribution of funds pursuant to the 
program--
          (1) to determine whether the current distribution 
        formula would require modification if the [contract 
        health service] purchased/referred care program were 
        funded at the level recommended by the Comptroller 
        General;
          (2) to identify any inequities in the current 
        distribution formula under the current funding level or 
        inequitable results for any Indian tribe under the 
        funding level recommended by the Comptroller General;
          (3) to identify any areas of program administration 
        that may result in the inefficient or ineffective 
        management of the program; and
          (4) to identify any other issues and recommendations 
        to improve the administration of the [contract health 
        services] purchased/referred care program and correct 
        any unfair results or funding disparities identified 
        under paragraph (2).
  (c) Subsequent Action by Secretary.--If, after consultation 
with Indian tribes under subsection (b), the Secretary 
determines that any issue described in subsection (b)(2) 
exists, the Secretary may initiate procedures under subchapter 
III of chapter 5 of title 5, United States Code, to negotiate 
or promulgate regulations to establish a disbursement formula 
for the [contract health service] purchased/referred care 
program funding.

TITLE III--HEALTH FACILITIES

           *       *       *       *       *       *       *


SEC. 307. INDIAN HEALTH CARE DELIVERY DEMONSTRATION PROJECTS.

  (a) Purpose and General Authority.--
          (1) Purpose.--The purpose of this section is to 
        encourage the establishment of demonstration projects 
        that meet the applicable criteria of this section to be 
        carried out by the Secretary, acting through the 
        Service, or Indian tribes or tribal organizations 
        acting pursuant to contracts or compacts under the 
        Indian Self Determination and Education Assistance Act 
        (25 U.S.C. 450 et seq.)--
                  (A) to test alternative means of delivering 
                health care and services to Indians through 
                facilities; or
                  (B) to use alternative or innovative methods 
                or models of delivering health care services to 
                Indians (including primary care services, 
                [contract health services] purchased/referred 
                care, or any other program or service 
                authorized by this Act) through convenient care 
                services (as defined in subsection (c)), 
                community health centers, or cooperative 
                agreements or arrangements with other health 
                care providers that share or coordinate the use 
                of facilities, funding, or other resources, or 
                otherwise coordinate or improve the 
                coordination of activities of the Service, 
                Indian tribes, or tribal organizations, with 
                those of the other health care providers.
          (2) Authority.--The Secretary, acting through the 
        Service, is authorized to carry out, or to 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 
        to carry out, health care delivery demonstration 
        projects that--
                  (A) test alternative means of delivering 
                health care and services to Indians through 
                facilities; or
                  (B) otherwise carry out the purposes of this 
                section.
  (b) Use of Funds.--The Secretary, in approving projects 
pursuant to this section--
          (1) may authorize such contracts for the construction 
        and renovation of hospitals, health centers, health 
        stations, and other facilities to deliver health care 
        services; and
          (2) is authorized--
                  (A) to waive any leasing prohibition;
                  (B) to permit use and carryover of funds 
                appropriated for the provision of health care 
                services under this Act (including for the 
                purchase of health benefits coverage, as 
                authorized by section 402(a));
                  (C) to permit the use of other available 
                funds, including other Federal funds, funds 
                from third-party collections in accordance with 
                sections 206, 207, and 401, and non-Federal 
                funds contributed by State or local 
                governmental agencies or facilities or private 
                health care providers pursuant to cooperative 
                or other agreements with the Service, 1 or more 
                Indian tribes, or tribal organizations;
                  (D) to permit the use of funds or property 
                donated or otherwise provided from any source 
                for project purposes;
                  (E) to provide for the reversion of donated 
                real or personal property to the donor; and
                  (F) to permit the use of Service funds to 
                match other funds, including Federal funds.
  (c) Health Care Demonstration Projects.--
          (1) Definition of convenient care service.--In this 
        subsection, the term ``convenient care service'' means 
        any primary health care service, such as urgent care 
        services, nonemergent care services, prevention 
        services and screenings, and any service authorized by 
        section 203 or 205(d), that is offered--
                  (A) at an alternative setting; or
                  (B) during hours other than regular working 
                hours.
          (2) General projects.--
                  (A) Criteria.--The Secretary may approve 
                under this section demonstration projects that 
                meet the following criteria:
                          (i) There is a need for a new 
                        facility or program, such as a program 
                        for convenient care services, or an 
                        improvement in, increased efficiency 
                        at, or reorientation of an existing 
                        facility or program.
                          (ii) A significant number of Indians, 
                        including Indians with low health 
                        status, will be served by the project.
                          (iii) The project has the potential 
                        to deliver services in an efficient and 
                        effective manner.
                          (iv) The project is economically 
                        viable.
                          (v) For projects carried out by an 
                        Indian tribe or tribal organization, 
                        the Indian tribe or tribal organization 
                        has the administrative and financial 
                        capability to administer the project.
                          (vi) The project is integrated with 
                        providers of related health or social 
                        services (including State and local 
                        health care agencies or other health 
                        care providers) and is coordinated 
                        with, and avoids duplication of, 
                        existing services in order to expand 
                        the availability of services.
                  (B) Priority.--In approving demonstration 
                projects under this paragraph, the Secretary 
                shall give priority to demonstration projects, 
                to the extent the projects meet the criteria 
                described in subparagraph (A), located in any 
                of the following Service units:
                          (i) Cass Lake, Minnesota.
                          (ii) Mescalero, New Mexico.
                          (iii) Owyhee and Elko, Nevada.
                          (iv) Schurz, Nevada.
                          (v) Ft. Yuma, California.
          (3) Innovative health services delivery demonstration 
        project.--
                  (A) Application or request.--On receipt of an 
                application or request from an Indian tribe, a 
                consortium of Indian tribes, or a tribal 
                organization within a Service area, the 
                Secretary shall take into consideration 
                alternative or innovated methods to deliver 
                health care services within the Service area 
                (or a portion of, or facility within, the 
                Service area) as described in the application 
                or request, including medical, dental, 
                pharmaceutical, nursing, clinical laboratory, 
                [contract health services] purchased/referred 
                care, convenient care services, community 
                health centers, or any other health care 
                services delivery models designed to improve 
                access to, or efficiency or quality of, the 
                health care, health promotion, or disease 
                prevention services and programs under this 
                Act.
                  (B) Approval.--In addition to projects 
                described in paragraph (2), in any fiscal year, 
                the Secretary is authorized under this 
                paragraph to approve not more than 10 
                applications for health care delivery 
                demonstration projects that meet the criteria 
                described in subparagraph (C).
                  (C) Criteria.--The Secretary shall approve 
                under subparagraph (B) demonstration projects 
                that meet all of the following criteria:
                          (i) The criteria set forth in 
                        paragraph (2)(A).
                          (ii) There is a lack of access to 
                        health care services at existing health 
                        care facilities, which may be due to 
                        limited hours of operation at those 
                        facilities or other factors.
                          (iii) The project--
                                  (I) expands the availability 
                                of services; or
                                  (II) reduces--
                                          (aa) the burden on 
                                        Contract Health 
                                        Services; or
                                          (bb) the need for 
                                        emergency room visits.
  (d) Technical Assistance.--On receipt of an application or 
request from an Indian tribe, a consortium of Indian tribes, or 
a tribal organization, the Secretary shall provide such 
technical and other assistance as may be necessary to enable 
applicants to comply with this section, including information 
regarding the Service unit budget and available funding for 
carrying out the proposed demonstration project.
  (e) Service to Ineligible Persons.--Subject to section 813, 
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 813, 
may be included, subject to the terms of that section, in any 
demonstration project approved pursuant to this section.
  (f) Equitable Treatment.--For purposes of subsection (c), the 
Secretary, 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.), shall use the same 
criteria that the Secretary uses in evaluating facilities 
operated directly by the Service.
  (g) Equitable Integration of Facilities.--The Secretary shall 
ensure that the planning, design, construction, renovation, and 
expansion needs of Service and non-Service facilities that 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.

           *       *       *       *       *       *       *


                  TITLE IV--ACCESS TO HEALTH SERVICES

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

  (a) Disregard of Medicare, Medicaid, and CHIP 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 XI 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 title 
                XVIII or XIX 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 either 
                such title.
                  (B) Use of funds.--Amounts received by a 
                facility of the Service under subparagraph (A) 
                by reason of a provision of title XVIII or XIX 
                of the Social Security Act 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 such respective 
                title. 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 in section 201(c)) 
                of such Indian tribes, including the provision 
                of services pursuant to section 205.
          (2) Direct payment option.--Paragraph (1) shall not 
        apply to a tribal health program upon the election of 
        such program under subsection (d) to receive payments 
        directly. No payment may be made out of the special 
        fund described in such paragraph with respect to 
        reimbursement made for services provided by such 
        program during the period of such election.
  (d) Direct Billing.--
          (1) In general.--Subject to complying with the 
        requirements of paragraph (2), a tribal health program 
        may elect to directly bill for, and receive payment 
        for, health care items and services provided by such 
        program for which payment is made under title XVIII, 
        XIX, or XXI of the Social Security Act or from any 
        other third party payor.
          (2) Direct reimbursement.--
                  (A) Use of funds.--Each tribal health program 
                making the election described in paragraph (1) 
                with respect to a program under a title of the 
                Social Security Act shall be reimbursed 
                directly by that program for items and services 
                furnished without regard to subsection (c)(1), 
                except that all amounts so reimbursed shall be 
                used by the tribal health program for the 
                purpose of making any improvements in 
                facilities of the tribal health program 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 (including coverage for a service or 
                service within a [contract health service] 
                purchased/referred care delivery area or any 
                portion of a [contract health service] 
                purchased/referred care delivery area that 
                would otherwise be provided as a [contract 
                health service] purchased/referred care), or 
                otherwise to achieve the objectives provided in 
                section 3 of this Act.
                  (B) Audits.--The amounts paid to a tribal 
                health program making the election described in 
                paragraph (1) with respect to a program under 
                title XVIII, XIX, or XXI 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 that receives 
                reimbursements or payments under title XVIII, 
                XIX, or XXI of the Social Security Act shall 
                provide to the Service a list of each provider 
                enrollment number (or other identifier) under 
                which such program receives such reimbursements 
                or payments.
          (3) Examination and implementation of changes.--
                  (A) In general.--The Secretary, acting 
                through the Service and with the assistance of 
                the Administrator of the 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 title XIX or XXI 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, 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 
        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 in the 
        direct billing program established under this 
        subsection if the Secretary determines that the program 
        has failed to comply with the requirements of paragraph 
        (2). The Secretary shall provide a tribal health 
        program with notice of a determination that the program 
        has failed to comply with any such requirement and a 
        reasonable opportunity to correct such noncompliance 
        prior to terminating the program's participation in the 
        direct billing program established under this 
        subsection.
  (e) Related Provisions Under the Social Security Act.--For 
provisions related to subsections (c) and (d), see sections 
1880, 1911, and 2107(e)(1)(D) of the Social Security Act.

SEC. 402. 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 
404) 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 (including coverage for a service, or service within a 
[contract health service] purchased/referred care delivery 
area, or any portion of a [contract health service] purchased/
referred care delivery area that would otherwise be provided as 
a [contract health service] purchased/referred care) 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;
          (4) a self-insured plan; or
          (5) a high deductible or health savings account plan.
  (b) Financial Need.--The purchase of coverage under 
subsection (a) by an Indian tribe, tribal organization, or 
urban Indian organization may be based on the financial needs 
of such beneficiaries (as determined by the 1 or more Indian 
tribes being served based on a schedule of income levels 
developed or implemented by such 1 ore more Indian tribes).
  (c) 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.
  (d) Construction.--Nothing in this section shall be construed 
as affecting the use of any amounts not referred to in 
subsection (a).

           *       *       *       *       *       *       *


TITLE VI--ORGANIZATIONAL IMPROVEMENTS

           *       *       *       *       *       *       *


SEC. 605. IMPROVEMENTS IN HIRING PRACTICES.

  (a) Direct Hire Authority.--The Secretary may appoint, 
without regard to subchapter I of chapter 33 of title 5, United 
States Code (other than sections 3303 and 3328 of such title), 
a candidate directly to a position within the Service for which 
the candidate meets the qualifications standard established by 
the Office of Personnel Management.
  (b) Tribal Notification.--Before appointing, hiring, 
promoting, transferring, or reassigning a candidate to a Senior 
Executive Service position or the position of a manager at an 
Area office or Service unit, the Secretary shall provide notice 
to each Indian Tribe located within the defined geographic area 
of such Area office or Service unit, as the case may be, of the 
content of an inclusion in an employment record. Each such 
Indian Tribe may submit comment to the Secretary during the 10-
day period after the date of such notification regarding such 
content.

SEC. 606. IMPROVED AUTHORITIES OF SECRETARY TO IMPROVE ACCOUNTABILITY 
                    OF SENIOR EXECUTIVES OF THE INDIAN HEALTH SERVICE.

  (a) Authority.--
          (1) In general.--The Secretary may, as provided in 
        this section, reprimand or suspend, involuntarily 
        reassign, demote, or remove a covered individual from a 
        senior executive position at the Service if the 
        Secretary determines that the misconduct or performance 
        of the covered individual warrants such action.
          (2) Removal from civil service.--If the Secretary 
        removes an individual pursuant to paragraph (1), the 
        Secretary may remove the individual from the civil 
        service (as defined in section 2101 of title 5, United 
        States Code).
  (b) Rights and Procedures.--
          (1) In general.--A covered individual who is the 
        subject of an action under subsection (a) is entitled 
        to--
                  (A) advance notice of the action and a file 
                containing all evidence in support of the 
                proposed action;
                  (B) be represented by an attorney or other 
                representative of the covered individual's 
                choice; and
                  (C) grieve the action in accordance with an 
                internal grievance process that the Secretary 
                shall establish for purposes of this 
                subsection.
          (2) Notice.--
                  (A) Aggregate period for notice.--The 
                aggregate period for notice, response, and 
                decision on an action under subsection (a) may 
                not exceed 15 business days.
                  (B) Response.--The period for the response of 
                a covered individual to a notice under 
                paragraph (1)(A) of an action under subsection 
                (a) shall be 7 business days.
                  (C) Decision.--A decision under this 
                paragraph on an action under subsection (a) 
                shall be issued not later than 15 business days 
                after notice of the action is provided to the 
                covered individual under paragraph (1)(A). The 
                decision shall be in writing, and shall include 
                the specific reasons for the decision.
          (3) Grievance process.--The Secretary shall ensure 
        that the grievance process established under paragraph 
        (1)(C) takes fewer than 21 days.
          (4) Final and conclusive decision.--A decision under 
        paragraph (2) that is not grieved, and a grievance 
        decision under paragraph (3), shall be final and 
        conclusive.
          (5) Judicial review.--A covered individual adversely 
        affected by a decision under paragraph (2) that is not 
        grieved, or by a grievance decision under paragraph 
        (3), may obtain judicial review of such decision.
          (6) Court review.--In any case in which judicial 
        review is sought under paragraph (5), the court shall 
        review the record and may set aside any Department 
        action found to be--
                  (A) arbitrary, capricious, an abuse of 
                discretion, or otherwise not in accordance with 
                a provision of law;
                  (B) obtained without procedures required by a 
                provision of law having been followed; or
                  (C) unsupported by substantial evidence.
  (c) Relation to Other Provisions of Law.--Section 3592(b)(1) 
of title 5, United States Code, does not apply to an action 
under subsection (a).
  (d) Definitions.--In this section:
          (1) Covered individual.--The term ``covered 
        individual'' means a career appointee (as that term is 
        defined in section 3132(a) of title 5, United States 
        Code).
          (2) Misconduct.--The term ``misconduct'' includes 
        neglect of duty, malfeasance, or failure to accept a 
        directed reassignment or to accompany a position in a 
        transfer of function.
          (3) Secretary.--The term ``Secretary'' means the 
        Secretary of Health and Human Services, acting through 
        the Director of the Service.
          (4) Senior executive position.--The term ``senior 
        executive position'' means a Senior Executive Service 
        position (as that term is defined in section 3132(a) of 
        title 5, United States Code).

SEC. 607. IMPROVED AUTHORITIES OF SECRETARY TO IMPROVE ACCOUNTABILITY 
                    OF EMPLOYEES OF THE INDIAN HEALTH SERVICE.

  (a) In General.--
          (1) Authority.--The Secretary may remove, demote, or 
        suspend a covered individual who is an employee of the 
        Service if the Secretary determines the performance or 
        misconduct of the covered individual warrants such 
        removal, demotion, or suspension.
          (2) Actions.--If the Secretary removes, demotes, or 
        suspends a covered individual pursuant to paragraph 
        (1), the Secretary may--
                  (A) remove the covered individual from the 
                civil service (as defined in section 2101 of 
                title 5, United States Code);
                  (B) demote the covered individual by means of 
                a reduction in grade for which the covered 
                individual is qualified, that the Secretary 
                determines is appropriate, and that reduces the 
                annual rate of pay of the covered individual; 
                or
                  (C) suspend the covered individual.
  (b) Pay of Certain Demoted Individuals.--
          (1) In general.--Notwithstanding any other provision 
        of law, any covered individual subject to a demotion 
        under subsection (a)(2) shall, beginning on the date of 
        such demotion, receive the annual rate of pay 
        applicable to such grade.
          (2) Restrictions.--
                  (A) Prohibition on administrative leave.--A 
                covered individual subject to a demotion under 
                subsection (a)(2) may not be placed on 
                administrative leave during the period during 
                which an appeal (if any) under this section is 
                ongoing, and may only receive pay if the 
                covered individual reports for duty or is 
                approved to use accrued unused annual, sick, 
                family medical, military, or court leave.
                  (B) Restriction on pay and benefits.--If a 
                covered individual subject to a demotion under 
                subsection (a)(2) does not report for duty or 
                receive approval to use accrued unused leave, 
                such covered individual shall not receive pay 
                or other benefits pursuant to subsection 
                (d)(5).
  (c) Procedures.--
          (1) In general.--
                  (A) Aggregate period.--The aggregate period 
                for notice, response, and final decision in a 
                removal, demotion, or suspension under this 
                section may not exceed 15 business days.
                  (B) Period for response.--The period for the 
                response of a covered individual to a notice of 
                a proposed removal, demotion, or suspension 
                under this section shall be 7 business days.
                  (C) Representation by attorney or other 
                representative.--Paragraph (3) of subsection 
                (b) of section 7513 of title 5, United States 
                Code, shall apply with respect to a removal, 
                demotion, or suspension under this section.
                  (D) Procedures superseding cbas.--The 
                procedures in this subsection shall supersede 
                any collective bargaining agreement to the 
                extent that such agreement is inconsistent with 
                such procedures.
          (2) Final decision.--The Secretary shall issue a 
        final decision with respect to a removal, demotion, or 
        suspension under this section not later than 15 
        business days after the Secretary provides notice, 
        including a file containing all the evidence in support 
        of the proposed action, to the covered individual of 
        the removal, demotion, or suspension. The decision 
        shall be in writing and shall include the specific 
        reasons for the decision.
          (3) Performance appraisal.--The procedures under 
        chapter 43 of title 5, United States Code, shall not 
        apply to a removal, demotion, or suspension under this 
        section.
          (4) Appeal to merit systems protection board.--
                  (A) In general.--Subject to subparagraph (B) 
                and subsection (d), any removal or demotion 
                under this section, and any suspension of more 
                than 14 days under this section, may be 
                appealed to the Merit Systems Protection Board, 
                which shall refer such appeal to an 
                administrative judge pursuant to section 
                7701(b)(1) of title 5, United States Code.
                  (B) Time period.--An appeal under 
                subparagraph (A) of a removal, demotion, or 
                suspension may only be made if such appeal is 
                made not later than 10 business days after the 
                date of such removal, demotion, or suspension.
  (d) Expedited Review.--
          (1) In general.--Upon receipt of an appeal under 
        subsection (c)(4)(A), the administrative judge shall 
        expedite any such appeal under section 7701(b)(1) of 
        title 5, United States Code, and, in any such case, 
        shall issue a final and complete decision not later 
        than 180 days after the date of the appeal.
          (2) Upholding decision.--
                  (A) In general.--Notwithstanding section 
                7701(c)(1)(B) of title 5, United States Code, 
                the administrative judge shall uphold the 
                decision of the Secretary to remove, demote, or 
                suspend an employee under subsection (a) if the 
                decision is supported by substantial evidence.
                  (B) Prohibition of mitigation.--
                Notwithstanding title 5, United States Code, or 
                any other provision of law, if the decision of 
                the Secretary is supported by substantial 
                evidence, the administrative judge shall not 
                mitigate the penalty prescribed by the 
                Secretary.
          (3) Appeal to merit systems protection board.--
                  (A) In general.--The decision of the 
                administrative judge under paragraph (1) may be 
                appealed to the Merit Systems Protection Board.
                  (B) Upholding decision.--Notwithstanding 
                section 7701(c)(1)(B) of title 5, United States 
                Code, the Merit Systems Protection Board shall 
                uphold the decision of the Secretary to remove, 
                demote, or suspend an employee under subsection 
                (a) if the decision is supported by substantial 
                evidence.
                  (C) Prohibition of mitigation.--
                Notwithstanding title 5, United States Code, or 
                any other provision of law, if the decision of 
                the Secretary is supported by substantial 
                evidence, the Merit Systems Protection Board 
                shall not mitigate the penalty prescribed by 
                the Secretary.
          (4) Report.--In any case in which the administrative 
        judge cannot issue a decision in accordance with the 
        180-day requirement under paragraph (1), the Merit 
        Systems Protection Board shall, not later than 14 
        business days after the expiration of the 180-day 
        period, submit to the appropriate committees of 
        Congress a report that explains the reasons why a 
        decision was not issued in accordance with such 
        requirement.
          (5) Appeal.--A decision of the Merit Systems 
        Protection Board under paragraph (3) may be appealed to 
        the United States Court of Appeals for the Federal 
        Circuit pursuant to section 7703 of title 5, United 
        States Code, or to any court of appeals of competent 
        jurisdiction pursuant to subsection (b)(1)(B) of such 
        section.
          (6) Prohibition against stays.--The Merit Systems 
        Protection Board may not stay any removal or demotion 
        under this section, except as provided in section 
        1214(b) of title 5, United States Code.
          (7) Restriction on pay and benefits during appeal.--
        During the period beginning on the date on which a 
        covered individual appeals a removal from the civil 
        service under subsection (c) and ending on the date 
        that the United States Court of Appeals for the Federal 
        Circuit issues a final decision on such appeal, such 
        covered individual may not receive any pay, awards, 
        bonuses, incentives, allowances, differentials, student 
        loan repayments, special payments, or benefits related 
        to the employment of the individual by the Service.
          (8) Information to expedite appeal.--To the maximum 
        extent practicable, the Secretary shall provide to the 
        Merit Systems Protection Board such information and 
        assistance as may be necessary to ensure an appeal 
        under this subsection is expedited.
          (9) Backpay.--If an employee prevails on appeal under 
        this section, the employee shall be entitled to backpay 
        (as provided in section 5596 of title 5, United States 
        Code).
          (10) Applicable timelines and procedures.--If an 
        employee who is subject to a collective bargaining 
        agreement chooses to grieve an action taken under this 
        section through a grievance procedure provided under 
        the collective bargaining agreement, the timelines and 
        procedures set forth in subsection (c) and this 
        subsection shall apply.
  (e) Alleged Prohibited Personnel Practice.--In the case of a 
covered individual seeking corrective action (or on behalf of 
whom corrective action is sought) from the Office of Special 
Counsel based on an alleged prohibited personnel practice 
described in section 2302(b) of title 5, United States Code, 
the Secretary may not remove, demote, or suspend such covered 
individual under subsection (a) without the approval of the 
Special Counsel under section 1214(f) of title 5, United States 
Code.
  (f) Termination of Investigations by Office of Special 
Counsel.--
          (1) In general.--Notwithstanding any other provision 
        of law, the Special Counsel (established by section 
        1211 of title 5, United States Code) may terminate an 
        investigation of a prohibited personnel practice 
        alleged by an employee or former employee of the 
        Service after the Special Counsel provides to the 
        employee or former employee a written statement of the 
        reasons for the termination of the investigation.
          (2) Admissibility.--The statement described in 
        paragraph (1) may not be admissible as evidence in any 
        judicial or administrative proceeding without the 
        consent of the employee or former employee described in 
        paragraph (1).
  (g) Vacancies.--In the case of a covered individual who is 
removed or demoted under subsection (a), to the maximum extent 
feasible, the Secretary shall fill the vacancy arising as a 
result of such removal or demotion.
  (h) Definitions.--In this section:
          (1) Covered individual.--The term ``covered 
        individual'' means an individual occupying a position 
        at the Service, but does not include--
                  (A) an individual occupying a senior 
                executive position (as defined in section 
                606(d));
                  (B) an individual who has not completed a 
                probationary or trial period; or
                  (C) a political appointee.
          (2) Grade.--The term ``grade'' has the meaning given 
        such term in section 7511(a) of title 5, United States 
        Code.
          (3) Misconduct.--The term ``misconduct'' includes 
        neglect of duty, malfeasance, or failure to accept a 
        directed reassignment or to accompany a position in a 
        transfer of function.
          (4) Political appointee.--The term ``political 
        appointee'' means an individual who is--
                  (A) employed in a position described under 
                sections 5312 through 5316 of title 5, United 
                States Code (relating to the Executive 
                Schedule);
                  (B) a limited term appointee, limited 
                emergency appointee, or noncareer appointee in 
                the Senior Executive Service, as defined under 
                paragraphs (5), (6), and (7), respectively, of 
                section 3132(a) of title 5, United States Code; 
                or
                  (C) employed in a position of a confidential 
                or policy-determining character under schedule 
                C of subpart C of part 213 of title 5, Code of 
                Federal Regulations, or successor regulation.
          (5) Secretary.--The term ``Secretary'' means the 
        Secretary of Health and Human Services, acting through 
        the Director of the Service.
          (6) Suspend.--The term ``suspend'' means the placing 
        of an employee, for disciplinary reasons, in a 
        temporary status without duties and pay for a period in 
        excess of 14 days.

SEC. 608. EMPLOYEE PROTECTIONS AGAINST RETALIATION.

  (a) Employee Accountability.--
          (1) Agency reporting process requirement.--The 
        Secretary shall designate an official in the Department 
        who is not an employee of the Service to--
                  (A) receive reports from an employee of the 
                Service who witnesses retaliation against a 
                whistleblower, a violation of a patient safety 
                requirement, or other similar conduct; and
                  (B) conduct active and ongoing outreach to 
                all employees of the Service about--
                          (i) Federal and Department systems 
                        for reporting retaliation against 
                        whistleblowers; and
                          (ii) the duty of individual employees 
                        of the Service to report violations of 
                        patient safety requirements and other 
                        similar conduct.
          (2) Oversight.--Not later than 3 days after the date 
        on which the official designated by the Secretary under 
        paragraph (1) receives a report under paragraph (1)(A), 
        the Secretary shall--
                  (A) formally review the report; and
                  (B) provide a copy of such report and any 
                other relevant information to the Inspector 
                General of the Department.
          (3) Removal for whistleblower retaliation.--The 
        Secretary may remove for misconduct from the civil 
        service (as defined in section 2101 of title 5, United 
        States Code), in accordance with sections 606 and 607, 
        an employee of the Service if the Secretary determines, 
        after completing a report review described in paragraph 
        (2), that the employee has retaliated against a 
        whistleblower and warrants removal.
          (4) Enhancing protections for whistleblowers.--The 
        Secretary shall carry out any actions determined 
        necessary by the Secretary to enhance protection for 
        whistleblowers, including identifying appropriate 
        Service employees and requiring the employees to 
        complete the Office of Special Counsel's Whistleblower 
        Certification Program.
  (b) Definitions.--In this section:
          (1) Retaliation.--The term ``retaliation''--
                  (A) means an adverse employment action or any 
                significantly adverse action against a 
                whistleblower, such as the refusal or delay of 
                care provided through the Service; and
                  (B) includes instances where the adverse 
                action described in subparagraph (A) is 
                perpetrated against a family member or friend 
                of the whistleblower because of the 
                whistleblower's disclosure of information.
          (2) Whistleblower.--The term ``whistleblower'' means 
        an employee of Service who discloses information--
                  (A) that the employee reasonably believes 
                evidences--
                          (i) a violation of any law, rule, or 
                        regulation; or
                          (ii) gross mismanagement, a gross 
                        waste of funds, an abuse of authority, 
                        or a substantial and specific danger to 
                        public health or safety; and
                  (B) if such disclosure is not specifically 
                prohibited by law and if such information is 
                not specifically required by Executive Order to 
                be kept secret in the interest of national 
                defense or the conduct of foreign affairs.

SEC. 609. FISCAL ACCOUNTABILITY.

  (a) Management of Funds.--
          (1) In general.--If the Secretary fails to submit the 
        professional housing plan under section 301(a) of the 
        Restoring Accountability in the Indian Health Service 
        Act of 2018 or the staffing plan under section 301(b) 
        of that Act, the Secretary may not receive, obligate, 
        transfer, or expend any amounts for a salary increase 
        or bonus of an individual described in paragraph (2) 
        until the professional housing plan or staffing plan, 
        as the case may be, is submitted.
          (2) Individual described.--An individual described in 
        this paragraph is an individual employed in a position 
        in the Service that is a position--
                  (A) described under sections 5312 through 
                5316 of title 5, United States Code;
                  (B) placed in level IV or V of the Executive 
                Schedule under section 5317 of title 5, United 
                States Code;
                  (C) as a limited term appointee, limited 
                emergency appointee, or noncareer appointee in 
                the Senior Executive Service, as defined under 
                paragraphs (5), (6), and (7), respectively, of 
                section 3132(a) of title 5, United States Code; 
                or
                  (D) under section 213.3301 or 213.3302 of 
                title 5, Code of Federal Regulations.
  (b) Prioritization of Patient Care.--
          (1) In general.--Notwithstanding any other provision 
        of law, the Secretary shall use amounts available to 
        the Indian Health Service that are not obligated or 
        expended, including base budget funding and third party 
        collections, during the fiscal year for which the 
        amounts are made available, and that remain available, 
        only to support patient care by using such funds for 
        the costs of--
                  (A) essential medical equipment;
                  (B) purchased or referred care; or
                  (C) staffing.
          (2) Special rule.--In using amounts under paragraph 
        (1), the Secretary shall ensure that, in any case where 
        the amounts were originally made available for a 
        particular Service unit, such amounts are used to 
        benefit Indians served by that Service unit.
          (3) Restrictions.--The Secretary may not use amounts 
        described in paragraph (1)--
                  (A) to remodel or interior decorate any Area 
                office; or
                  (B) to increase the rate of pay of any 
                employee of an Area office.
  (c) Spending Reports.--Not later than 90 days after the end 
of each quarter of a fiscal year, the Secretary shall submit a 
report describing the authorizations, expenditures, outlays, 
transfers, reprogramming, and obligations of each level of the 
Service, including the headquarters, each Area office, each 
Service unit, and each health clinic or facility, to--
          (1) each Indian Tribe;
          (2) in the Senate--
                  (A) the Committee on Indian Affairs;
                  (B) the Committee on Health, Education, 
                Labor, and Pensions;
                  (C) the Committee on Appropriations; and
                  (D) the Committee on the Budget; and
          (3) in the House of Representatives--
                  (A) the Committee on Natural Resources;
                  (B) the Committee on Energy and Commerce;
                  (C) the Committee on Appropriations; and
                  (D) the Committee on the Budget.
  (d) Status Reports.--
          (1) In general.--Subject to paragraph (2), not later 
        than 180 days after the end of each fiscal year, the 
        Secretary shall provide to each entity described in 
        paragraphs (1) through (3) of subsection (c) a report 
        describing the safety, billing, certification, 
        credential, and compliance statuses of each facility 
        managed, operated, or otherwise supported by the 
        Service.
          (2) Updates.--With respect to any change of a status 
        described in paragraph (1), the Secretary shall 
        immediately provide to each entity described in 
        paragraphs (1) through (3) of subsection (c) an update 
        describing such change.
  (e) Rule of Construction.--Nothing in this section may be 
construed--
          (1) to negatively impact the right of an Indian Tribe 
        to enter into a compact or contract under the Indian 
        Self-Determination and Education Assistance Act (25 
        U.S.C. 5304 et seq.); and
          (2) to apply to such a compact or contract unless 
        expressly agreed to by the Indian Tribe.

           *       *       *       *       *       *       *


TITLE VIII--MISCELLANEOUS

           *       *       *       *       *       *       *


SEC. 808. ARIZONA AS CONTRACT HEALTH SERVICE DELIVERY AREA.

  (a) In General.--The State of Arizona shall be designated as 
a [contract health service] purchased/referred care delivery 
area by the Service for the purpose of providing contract 
health care services to members of Indian tribes in the State 
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 the curtailment is due 
to the provision of contract services in that State pursuant to 
the designation of the State as a [contract health service] 
purchased/referred care delivery area by subsection (a).

SEC. 808A. NORTH DAKOTA AND SOUTH DAKOTA AS CONTRACT HEALTH SERVICE 
                    DELIVERY AREA.

  (a) In General.--The States of North Dakota and South Dakota 
shall be designated as a [contract health service] purchased/
referred care delivery area by the Service for the purpose of 
providing contract health care services to members of Indian 
tribes in the States of North Dakota and South Dakota.
  (b) Maintenance of Services.--The Service shall not curtail 
any health care services provided to Indians residing on any 
reservation, or in any county that has a common boundary with 
any reservation, in the State of North Dakota or South Dakota 
if the curtailment is due to the provision of contract services 
in those States pursuant to the designation of the States as a 
[contract health service] purchased/referred care delivery area 
by subsection (a).

           *       *       *       *       *       *       *


         CALIFORNIA AS A CONTRACT HEALTH SERVICE DELIVERY AREA

  Sec. 810. 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] purchased/referred care delivery area 
by the Service for the purpose of providing [contract health 
services] purchased/referred care to Indians in such State.

           *       *       *       *       *       *       *


         CONTRACT HEALTH SERVICES FOR THE TRENTON SERVICE AREA

  Sec. 815. (a) The Secretary, acting through the Service, is 
directed to provide [contract health services] purchased/
referred care 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) 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. 830. OTHER GAO REPORTS.

  (a) Coordination of Services.--
          (1) Study and evaluation.--The Comptroller General of 
        the United States shall conduct a study, and evaluate 
        the effectiveness, of coordination of health care 
        services provided to Indians--
                  (A) through Medicare, Medicaid, or SCHIP;
                  (B) by the Service; or
                  (C) using funds provided by--
                          (i) State or local governments; or
                          (ii) Indian tribes.
          (2) Report.--Not later than 18 months after the date 
        of enactment of the Indian Health Care Improvement 
        Reauthorization and Extension Act of 2009, the 
        Comptroller General shall submit to Congress a report--
                  (A) describing the results of the evaluation 
                under paragraph (1); and
                  (B) containing recommendations of the 
                Comptroller General regarding measures to 
                support and increase coordination of the 
                provision of health care services to Indians as 
                described in paragraph (1).
  (b) Payments for Contract Health Services.--
          (1) In general.--The Comptroller General shall 
        conduct a study on the use of health care furnished by 
        health care providers under the [contract health 
        services] purchased/referred care program funded by the 
        Service and operated by the Service, an Indian tribe, 
        or a tribal organization.
          (2) Analysis.--The study conducted under paragraph 
        (1) shall include an analysis of--
                  (A) the amounts reimbursed under the 
                [contract health services] purchased/referred 
                care program described in paragraph (1) for 
                health care furnished by entities, individual 
                providers, and suppliers, including a 
                comparison of reimbursement for that health 
                care through other public programs and in the 
                private sector;
                  (B) barriers to accessing care under such 
                [contract health services] purchased/referred 
                care program, including barriers relating to 
                travel distances, cultural differences, and 
                public and private sector reluctance to furnish 
                care to patients under the program;
                  (C) the adequacy of existing Federal funding 
                for health care under the [contract health 
                services] purchased/referred care program;
                  (D) the administration of the [contract 
                health service] purchased/referred care 
                program, including the distribution of funds to 
                Indian health programs pursuant to the program; 
                and
                  (E) any other items determined appropriate by 
                the Comptroller General.
          (3) Report.--Not later than 18 months after the date 
        of enactment of the Indian Health Care Improvement 
        Reauthorization and Extension Act of 2009, the 
        Comptroller General shall submit to Congress a report 
        on the study conducted under paragraph (1), together 
        with recommendations regarding--
                  (A) the appropriate level of Federal funding 
                that should be established for health care 
                under the [contract health services] purchased/
                referred care program described in paragraph 
                (1);
                  (B) how to most efficiently use that funding; 
                and
                  (C) the identification of any inequities in 
                the current distribution formula or inequitable 
                results for any Indian tribe under the funding 
                level, and any recommendations for addressing 
                any inequities or inequitable results 
                identified.
          (4) Consultation.--In conducting the study under 
        paragraph (1) and preparing the report under paragraph 
        (3), the Comptroller General shall consult with the 
        Service, Indian tribes, and tribal organizations.

           *       *       *       *       *       *       *


SEC. 833. STAFFING DEMONSTRATION PROJECT.

  (a) In General.--The Secretary, acting through the Service, 
shall establish a demonstration project that authorizes the 
Service to provide federally managed Service units with 
additional staffing resources with the goal that the resources 
become self-sustaining.
  (b) Selection.--In selecting Service units for participation, 
the Secretary shall consider whether a Service unit services an 
Indian Tribe that--
          (1) has utilized or contributed substantial tribal 
        funds to construct a health facility used by the 
        Service or identified in the master plan for the 
        Service unit;
          (2) is located in a State or States with Medicaid 
        reimbursements plans or policies that will increase the 
        likelihood that the staffing resources provided will be 
        self-sustaining; and
          (3) is operating a health facility described in 
        paragraph (1) under historical staffing ratios that 
        have not been equalized or updated by the Service or 
        any other Service program to reflect current staffing 
        needs.
  (c) Duration.--Staffing resources provided to a Service unit 
under this section shall be for a duration that the Secretary, 
in consultation with the applicable Indian Tribe, determines 
appropriate, except that each staffing position provided shall 
be for a period of not less than 3 fiscal years.
  (d) Effect of Staffing Awards.--No staffing resources 
provided under this section shall reduce the recurring base 
funding for staffing for any Indian Tribe or federally managed 
Service unit.
  (e) Report.--Not later than 5 years after the Secretary ends 
the demonstration project under this section, the Secretary 
shall prepare and submit a report to the Committee on Indian 
Affairs and the Committee on Health, Education, Labor, and 
Pensions of the Senate, and the Committee on Natural Resources 
and the Committee on Energy and Commerce of the House of 
Representatives, regarding the project, including--
          (1) whether the staffing resources resulted in 
        additional revenue for the Service unit sufficient to 
        maintain the staff on a permanent basis;
          (2) the levels to which the staffing resources 
        reduced the unmet staffing need for the Service unit; 
        and
          (3) whether the demonstration project could be 
        deployed to reduce unmet staffing needs throughout the 
        Service.

SEC. 834. RULE ESTABLISHING TRIBAL CONSULTATION POLICY.

  (a) In General.--Not later than 1 year after the date of 
enactment of the Restoring Accountability in the Indian Health 
Service Act of 2018, the Secretary shall establish, after 
meaningful consultation with representatives of affected Indian 
Tribes, a rule establishing a tribal consultation policy for 
the Service.
  (b) Contents of Tribal Consultation Policy.--The policy 
established under the rule described in subsection (a) shall--
          (1) update, and replace, the tribal consultation 
        policy established under Circular No. 2006-01 of the 
        Service, or any successor policy; and
          (2) include the following:
                  (A) A process for determining when the 
                Service will notify Indian Tribes, and a 
                description of how the Indian Tribes should be 
                notified.
                  (B) A determination of what actions or agency 
                decisions by the Service will trigger a 
                requirement for meaningful consultation with 
                Indian Tribes.
                  (C) A determination of what actions 
                constitute meaningful consultation with Indian 
                Tribes.
                              ----------                              


                       PUBLIC HEALTH SERVICE ACT



           *       *       *       *       *       *       *
         TITLE II--ADMINISTRATION AND MISCELLANEOUS PROVISIONS

Part A--Administration

           *       *       *       *       *       *       *


          defense of certain malpractice and negligence suits

  Sec. 224. (a) The remedy against the United States provided 
by sections 1346(b) and 2672 of title 28, or by alternative 
benefits provided by the United States where the availability 
of such benefits precludes a remedy under section 1346(b) of 
title 28, for damage for personal injury, including death, 
resulting from the performance of medical, surgical, dental, or 
related functions, including the conduct of clinical studies or 
investigation, by any commissioned officer or employee of the 
Public Health Service while acting within the scope of his 
office or employment, shall be exclusive of any other civil 
action or proceeding by reason of the same subject-matter 
against the officer or employee (or his estate) whose act or 
omission gave rise to the claim.
  (b) The Attorney General shall defend any civil action or 
proceeding brought in any court against any person referred to 
in subsection (a) of this section (or his estate) for any such 
damage or injury. Any such person against whom such civil 
action or proceeding is brought shall deliver within such time 
after date of service or knowledge of service as determined by 
the Attorney General, all process served upon him or an 
attested true copy thereof to his immediate superior or to 
whomever was designated by the Secretary to receive such papers 
and such persons shall promptly furnish copies of the pleading 
and process therein to the United States attorney for the 
district embracing the place wherein the proceeding is brought, 
to the Attorney General, and to the Secretary.
  (c) Upon a certification by the Attorney General that the 
defendant was acting in the scope of his employment at the time 
of the incident out of which the suit arose, any such civil 
action or proceeding commenced in a State court shall be 
removed without bond at any time before trial by the Attorney 
General to the district court of the United States of the 
district and division embracing the place wherein it is pending 
and the proceeding deemed a tort action brought against the 
United States under the provisions of title 28 and all 
references thereto. Should a United States district court 
determine on a hearing on a motion to remand held before a 
trial on the merit that the case so removed is one in which a 
remedy by suit within the meaning of subsection (a) of this 
section is not available against the United States, the case 
shall be remanded to the State Court: Provided, That where such 
a remedy is precluded because of the availability of a remedy 
through proceedings for compensation or other benefits from the 
United States as provided by any other law, the case shall be 
dismissed, but in the event the running of any limitation of 
time for commencing, or filing an application or claim in, such 
proceedings for compensation or other benefits shall be deemed 
to have been suspended during the pendency of the civil action 
or proceeding under this section.
  (d) The Attorney General may compromise or settle any claim 
asserted in such civil action or proceeding in the manner 
provided in section 2677 of title 28 and with the same effect.
  (e) For purposes of this section, the provisions of section 
2680(h) of title 28 shall not apply to assault or battery 
arising out of negligence in the performance of medical, 
surgical, dental, or related functions, including the conduct 
of clinical studies or investigations.
  (f) The Secretary or his designee may, to the extent that he 
deems appropriate, hold harmless or provide liability insurance 
for any officer or employee of the Public Health Service for 
damage for personal injury, including death, negligently caused 
by such officer or employee while acting within the scope of 
his office or employment and as a result of the performance of 
medical, surgical, dental, or related functions, including the 
conduct of clinical studies or investigations, if such employee 
is assigned to a foreign country or detailed to a State or 
political subdivision thereof or to a non-profit institution, 
and if the circumstances are such as are likely to preclude the 
remedies of third persons against the United States described 
in section 2679(b) of title 28, for such damage or injury.
  (g)(1)(A) For purposes of this section and subject to the 
approval by the Secretary of an application under subparagraph 
(D), an entity described in paragraph (4), and any officer, 
governing board member, or employee of such an entity, and any 
contractor of such an entity who is a physician or other 
licensed or certified health care practitioner (subject to 
paragraph (5)), shall be deemed to be an employee of the Public 
Health Service for a calendar year that begins during a fiscal 
year for which a transfer was made under subsection (k)(3) 
(subject to paragraph (3)). The remedy against the United 
States for an entity described in paragraph (4) and any 
officer, governing board member, employee, or contractor 
(subject to paragraph (5)) of such an entity who is deemed to 
be an employee of the Public Health Service pursuant to this 
paragraph shall be exclusive of any other civil action or 
proceeding to the same extent as the remedy against the United 
States is exclusive pursuant to subsection (a).
  (B) The deeming of any entity or officer, governing board 
member, employee, or contractor of the entity to be an employee 
of the Public Health Service for purposes of this section shall 
apply with respect to services provided--
          (i) to all patients of the entity, and
          (ii) subject to subparagraph (C), to individuals who 
        are not patients of the entity.
  (C) Subparagraph (B)(ii) applies to services provided to 
individuals who are not patients of an entity if the Secretary 
determines, after reviewing an application submitted under 
subparagraph (D), that the provision of the services to such 
individuals--
          (i) benefits patients of the entity and general 
        populations that could be served by the entity through 
        community-wide intervention efforts within the 
        communities served by such entity;
          (ii) facilitates the provision of services to 
        patients of the entity; or
          (iii) are otherwise required under an employment 
        contract (or similar arrangement) between the entity 
        and an officer, governing board member, employee, or 
        contractor of the entity.
  (D) The Secretary may not under subparagraph (A) deem an 
entity or an officer, governing board member, employee, or 
contractor of the entity to be an employee of the Public Health 
Service for purposes of this section, and may not apply such 
deeming to services described in subparagraph (B)(ii), unless 
the entity has submitted an application for such deeming to the 
Secretary in such form and such manner as the Secretary shall 
prescribe. The application shall contain detailed information, 
along with supporting documentation, to verify that the entity, 
and the officer, governing board member, employee, or 
contractor of the entity, as the case may be, meets the 
requirements of subparagraphs (B) and (C) of this paragraph and 
that the entity meets the requirements of paragraphs (1) 
through (4) of subsection (h).
  (E) The Secretary shall make a determination of whether an 
entity or an officer, governing board member, employee, or 
contractor of the entity is deemed to be an employee of the 
Public Health Service for purposes of this section within 30 
days after the receipt of an application under subparagraph 
(D). The determination of the Secretary that an entity or an 
officer, governing board member, employee, or contractor of the 
entity is deemed to be an employee of the Public Health Service 
for purposes of this section shall apply for the period 
specified by the Secretary under subparagraph (A).
  (F) Once the Secretary makes a determination that an entity 
or an officer, governing board member, employee, or contractor 
of an entity is deemed to be an employee of the Public Health 
Service for purposes of this section, the determination shall 
be final and binding upon the Secretary and the Attorney 
General and other parties to any civil action or proceeding. 
Except as provided in subsection (i), the Secretary and the 
Attorney General may not determine that the provision of 
services which are the subject of such a determination are not 
covered under this section.
  (G) In the case of an entity described in paragraph (4) that 
has not submitted an application under subparagraph (D):
          (i) The Secretary may not consider the entity in 
        making estimates under subsection (k)(1).
          (ii) This section does not affect any authority of 
        the entity to purchase medical malpractice liability 
        insurance coverage with Federal funds provided to the 
        entity under section 329, 330, or 340A.
  (H) In the case of an entity described in paragraph (4) for 
which an application under subparagraph (D) is in effect, the 
entity may, through notifying the Secretary in writing, elect 
to terminate the applicability of this subsection to the 
entity. With respect to such election by the entity:
          (i) The election is effective upon the expiration of 
        the 30-day period beginning on the date on which the 
        entity submits such notification.
          (ii) Upon taking effect, the election terminates the 
        applicability of this subsection to the entity and each 
        officer, governing board member, employee, and 
        contractor of the entity.
          (iii) Upon the effective date for the election, 
        clauses (i) and (ii) of subparagraph (G) apply to the 
        entity to the same extent and in the same manner as 
        such clauses apply to an entity that has not submitted 
        an application under subparagraph (D).
          (iv) If after making the election the entity submits 
        an application under subparagraph (D), the election 
        does not preclude the Secretary from approving the 
        application (and thereby restoring the applicability of 
        this subsection to the entity and each officer, 
        governing board member, employee, and contractor of the 
        entity, subject to the provisions of this subsection 
        and the subsequent provisions of this section.
  (2) If, with respect to an entity or person deemed to be an 
employee for purposes of paragraph (1), a cause of action is 
instituted against the United States pursuant to this section, 
any claim of the entity or person for benefits under an 
insurance policy with respect to medical malpractice relating 
to such cause of action shall be subrogated to the United 
States.
  (3) This subsection shall apply with respect to a cause of 
action arising from an act or omission which occurs on or after 
January 1, 1993.
  (4) An entity described in this paragraph is a public or non-
profit private entity receiving Federal funds under section 
330.
  (5) For purposes of paragraph (1), an individual may be 
considered a contractor of an entity described in paragraph (4) 
only if--
          (A) the individual normally performs on average at 
        least 32\1/2\ hours of service per week for the entity 
        for the period of the contract; or
          (B) in the case of an individual who normally 
        performs an average of less than 32\1/2\ hours of 
        services per week for the entity for the period of the 
        contract, the individual is a licensed or certified 
        provider of services in the fields of family practice, 
        general internal medicine, general pediatrics, or 
        obstetrics and gynecology.
  (h) The Secretary may not approve an application under 
subsection (g)(1)(D) unless the Secretary determines that the 
entity--
          (1) has implemented appropriate policies and 
        procedures to reduce the risk of malpractice and the 
        risk of lawsuits arising out of any health or health-
        related functions performed by the entity;
          (2) has reviewed and verified the professional 
        credentials, references, claims history, fitness, 
        professional review organization findings, and license 
        status of its physicians and other licensed or 
        certified health care practitioners, and, where 
        necessary, has obtained the permission from these 
        individuals to gain access to this information;
          (3) has no history of claims having been filed 
        against the United States as a result of the 
        application of this section to the entity or its 
        officers, employees, or contractors as provided for 
        under this section, or, if such a history exists, has 
        fully cooperated with the Attorney General in defending 
        against any such claims and either has taken, or will 
        take, any necessary corrective steps to assure against 
        such claims in the future; and
          (4) will fully cooperate with the Attorney General in 
        providing information relating to an estimate described 
        under subsection (k).
  (i)(1) Notwithstanding subsection (g)(1), the Attorney 
General, in consultation with the Secretary, may on the record 
determine, after notice and opportunity for a full and fair 
hearing, that an individual physician or other licensed or 
certified health care practitioner who is an officer, employee, 
or contractor of an entity described in subsection (g)(4) shall 
not be deemed to be an employee of the Public Health Service 
for purposes of this section, if treating such individual as 
such an employee would expose the Government to an unreasonably 
high degree of risk of loss because such individual--
          (A) does not comply with the policies and procedures 
        that the entity has implemented pursuant to subsection 
        (h)(1);
          (B) has a history of claims filed against him or her 
        as provided for under this section that is outside the 
        norm for licensed or certified health care 
        practitioners within the same specialty;
          (C) refused to reasonably cooperate with the Attorney 
        General in defending against any such claim;
          (D) provided false information relevant to the 
        individual's performance of his or her duties to the 
        Secretary, the Attorney General, or an applicant for or 
        recipient of funds under this Act; or
          (E) was the subject of disciplinary action taken by a 
        State medical licensing authority or a State or 
        national professional society.
  (2) A final determination by the Attorney General under this 
subsection that an individual physician or other licensed or 
certified health care professional shall not be deemed to be an 
employee of the Public Health Service shall be effective upon 
receipt by the entity employing such individual of notice of 
such determination, and shall apply only to acts or omissions 
occurring after the date such notice is received.
  (j) In the case of a health care provider who is an officer, 
employee, or contractor of an entity described in subsection 
(g)(4), section 335(e) shall apply with respect to the provider 
to the same extent and in the same manner as such section 
applies to any member of the National Health Service Corps.
  (k)(1)(A) For each fiscal year, the Attorney General, in 
consultation with the Secretary, shall estimate by the 
beginning of the year the amount of all claims which are 
expected to arise under this section (together with related 
fees and expenses of witnesses) for which payment is expected 
to be made in accordance with section 1346 and chapter 171 of 
title 28, United States Code, from the acts or omissions, 
during the calendar year that begins during that fiscal year, 
of entities described in subsection (g)(4) and of officers, 
employees, or contractors (subject to subsection (g)(5)) of 
such entities.
  (B) The estimate under subparagraph (A) shall take into 
account--
          (i) the value and frequency of all claims for damage 
        for personal injury, including death, resulting from 
        the performance of medical, surgical, dental, or 
        related functions by entities described in subsection 
        (g)(4) or by officers, employees, or contractors 
        (subject to subsection (g)(5)) of such entities who are 
        deemed to be employees of the Public Health Service 
        under subsection (g)(1) that, during the preceding 5-
        year period, are filed under this section or, with 
        respect to years occurring before this subsection takes 
        effect, are filed against persons other than the United 
        States,
          (ii) the amounts paid during that 5-year period on 
        all claims described in clause (i), regardless of when 
        such claims were filed, adjusted to reflect payments 
        which would not be permitted under section 1346 and 
        chapter 171 of title 28, United States Code, and
          (iii) amounts in the fund established under paragraph 
        (2) but unspent from prior fiscal years.
  (2) Subject to appropriations, for each fiscal year, the 
Secretary shall establish a fund of an amount equal to the 
amount estimated under paragraph (1) that is attributable to 
entities receiving funds under each of the grant programs 
described in paragraph (4) of subsection (g), but not to exceed 
a total of $10,000,000 for each such fiscal year. 
Appropriations for purposes of this paragraph shall be made 
separate from appropriations made for purposes of sections 329, 
330 and 340A.
  (3) In order for payments to be made for judgments against 
the United States (together with related fees and expenses of 
witnesses) pursuant to this section arising from the acts or 
omissions of entities described in subsection (g)(4) and of 
officers, employees, or contractors (subject to subsection 
(g)(5)) of such entities, the total amount contained within the 
fund established by the Secretary under paragraph (2) for a 
fiscal year shall be transferred not later than the December 31 
that occurs during the fiscal year to the appropriate accounts 
in the Treasury.
  (l)(1) If a civil action or proceeding is filed in a State 
court against any entity described in subsection (g)(4) or any 
officer, governing board member, employee, or any contractor of 
such an entity for damages described in subsection (a), the 
Attorney General, within 15 days after being notified of such 
filing, shall make an appearance in such court and advise such 
court as to whether the Secretary has determined under 
subsections (g) and (h), that such entity, officer, governing 
board member, employee, or contractor of the entity is deemed 
to be an employee of the Public Health Service for purposes of 
this section with respect to the actions or omissions that are 
the subject of such civil action or proceeding. Such advice 
shall be deemed to satisfy the provisions of subsection (c) 
that the Attorney General certify that an entity, officer, 
governing board member, employee, or contractor of the entity 
was acting within the scope of their employment or 
responsibility.
  (2) If the Attorney General fails to appear in State court 
within the time period prescribed under paragraph (1), upon 
petition of any entity or officer, governing board member, 
employee, or contractor of the entity named, the civil action 
or proceeding shall be removed to the appropriate United States 
district court. The civil action or proceeding shall be stayed 
in such court until such court conducts a hearing, and makes a 
determination, as to the appropriate forum or procedure for the 
assertion of the claim for damages described in subsection (a) 
and issues an order consistent with such determination.
  (m)(1) An entity or officer, governing board member, 
employee, or contractor of an entity described in subsection 
(g)(1) shall, for purposes of this section, be deemed to be an 
employee of the Public Health Service with respect to services 
provided to individuals who are enrollees of a managed care 
plan if the entity contracts with such managed care plan for 
the provision of services.
  (2) Each managed care plan which enters into a contract with 
an entity described in subsection (g)(4) shall deem the entity 
and any officer, governing board member, employee, or 
contractor of the entity as meeting whatever malpractice 
coverage requirements such plan may require of contracting 
providers for a calendar year if such entity or officer, 
governing board member, employee, or contractor of the entity 
has been deemed to be an employee of the Public Health Service 
for purposes of this section for such calendar year. Any plan 
which is found by the Secretary on the record, after notice and 
an opportunity for a full and fair hearing, to have violated 
this subsection shall upon such finding cease, for a period to 
be determined by the Secretary, to receive and to be eligible 
to receive any Federal funds under titles XVIII or XIX of the 
Social Security Act.
  (3) For purposes of this subsection, the term ``managed care 
plan'' shall mean health maintenance organizations and similar 
entities that contract at-risk with payors for the provision of 
health services or plan enrollees and which contract with 
providers (such as entities described in subsection (g)(4)) for 
the delivery of such services to plan enrollees.
  (n)(1) Not later than one year after the date of the 
enactment of the Federally Supported Health Centers Assistance 
Act of 1995, the Comptroller General of the United States shall 
submit to the Congress a report on the following:
          (A) The medical malpractice liability claims 
        experience of entities that have been deemed to be 
        employees for purposes of this section.
          (B) The risk exposure of such entities.
          (C) The value of private sector risk-management 
        services, and the value of risk-management services and 
        procedures required as a condition of receiving a grant 
        under section 329, 330, or 340A.
          (D) A comparison of the costs and the benefits to 
        taxpayers of maintaining medical malpractice liability 
        coverage for such entities pursuant to this section, 
        taking into account--
                  (i) a comparison of the costs of premiums 
                paid by such entities for private medical 
                malpractice liability insurance with the cost 
                of coverage pursuant to this section; and
                  (ii) an analysis of whether the cost of 
                premiums for private medical malpractice 
                liability insurance coverage is consistent with 
                the liability claims experience of such 
                entities.
  (2) The report under paragraph (1) shall include the 
following:
          (A) A comparison of--
                  (i) an estimate of the aggregate amounts that 
                such entities (together with the officers, 
                governing board members, employees, and 
                contractors of such entities who have been 
                deemed to be employees for purposes of this 
                section) would have directly or indirectly paid 
                in premiums to obtain medical malpractice 
                liability insurance coverage if this section 
                were not in effect; with
                  (ii) the aggregate amounts by which the 
                grants received by such entities under this Act 
                were reduced pursuant to subsection (k)(2).
          (B) A comparison of--
                  (i) an estimate of the amount of privately 
                offered such insurance that such entities 
                (together with the officers, governing board 
                members, employees, and contractors of such 
                entities who have been deemed to be employees 
                for purposes of this section) purchased during 
                the three-year period beginning on January 1, 
                1993; with
                  (ii) an estimate of the amount of such 
                insurance that such entities (together with the 
                officers, governing board members, employees, 
                and contractors of such entities who have been 
                deemed to be employees for purposes of this 
                section) will purchase after the date of the 
                enactment of the Federally Supported Health 
                Centers Assistance Act of 1995.
          (C) An estimate of the medical malpractice liability 
        loss history of such entities for the 10-year period 
        preceding October 1, 1996, including but not limited to 
        the following:
                  (i) Claims that have been paid and that are 
                estimated to be paid, and legal expenses to 
                handle such claims that have been paid and that 
                are estimated to be paid, by the Federal 
                Government pursuant to deeming entities as 
                employees for purposes of this section.
                  (ii) Claims that have been paid and that are 
                estimated to be paid, and legal expenses to 
                handle such claims that have been paid and that 
                are estimated to be paid, by private medical 
                malpractice liability insurance.
          (D) An analysis of whether the cost of premiums for 
        private medical malpractice liability insurance 
        coverage is consistent with the liability claims 
        experience of entities that have been deemed as 
        employees for purposes of this section.
  (3) In preparing the report under paragraph (1), the 
Comptroller General of the United States shall consult with 
public and private entities with expertise on the matters with 
which the report is concerned.
  (o)(1) For purposes of this section, a free clinic health 
professional shall in providing a qualifying health service to 
an individual, or an officer, governing board member, employee, 
or contractor of a free clinic shall in providing services for 
the free clinic, be deemed to be an employee of the Public 
Health Service for a calendar year that begins during a fiscal 
year for which a transfer was made under paragraph (6)(D). The 
preceding sentence is subject to the provisions of this 
subsection.
  (2) In providing a health service to an individual, a health 
care practitioner shall for purposes of this subsection be 
considered to be a free clinic health professional if the 
following conditions are met:
          (A) The service is provided to the individual at a 
        free clinic, or through offsite programs or events 
        carried out by the free clinic.
          (B) The free clinic is sponsoring the health care 
        practitioner pursuant to paragraph (5)(C).
          (C) The service is a qualifying health service (as 
        defined in paragraph (4)).
          (D) Neither the health care practitioner nor the free 
        clinic receives any compensation for the service from 
        the individual or from any third-party payor (including 
        reimbursement under any insurance policy or health 
        plan, or under any Federal or State health benefits 
        program). With respect to compliance with such 
        condition:
                  (i) The health care practitioner may receive 
                repayment from the free clinic for reasonable 
                expenses incurred by the health care 
                practitioner in the provision of the service to 
                the individual.
                  (ii) The free clinic may accept voluntary 
                donations for the provision of the service by 
                the health care practitioner to the individual.
          (E) Before the service is provided, the health care 
        practitioner or the free clinic provides written notice 
        to the individual of the extent to which the legal 
        liability of the health care practitioner is limited 
        pursuant to this subsection (or in the case of an 
        emergency, the written notice is provided to the 
        individual as soon after the emergency as is 
        practicable). If the individual is a minor or is 
        otherwise legally incompetent, the condition under this 
        subparagraph is that the written notice be provided to 
        a legal guardian or other person with legal 
        responsibility for the care of the individual.
          (F) At the time the service is provided, the health 
        care practitioner is licensed or certified in 
        accordance with applicable law regarding the provision 
        of the service.
  (3)(A) For purposes of this subsection, the term ``free 
clinic'' means a health care facility operated by a nonprofit 
private entity meeting the following requirements:
          (i) The entity does not, in providing health services 
        through the facility, accept reimbursement from any 
        third-party payor (including reimbursement under any 
        insurance policy or health plan, or under any Federal 
        or State health benefits program).
          (ii) The entity, in providing health services through 
        the facility, either does not impose charges on the 
        individuals to whom the services are provided, or 
        imposes a charge according to the ability of the 
        individual involved to pay the charge.
          (iii) The entity is licensed or certified in 
        accordance with applicable law regarding the provision 
        of health services.
  (B) With respect to compliance with the conditions under 
subparagraph (A), the entity involved may accept voluntary 
donations for the provision of services.
  (4) For purposes of this subsection, the term ``qualifying 
health service'' means any medical assistance required or 
authorized to be provided in the program under title XIX of the 
Social Security Act, without regard to whether the medical 
assistance is included in the plan submitted under such program 
by the State in which the health care practitioner involved 
provides the medical assistance. References in the preceding 
sentence to such program shall as applicable be considered to 
be references to any successor to such program.
  (5) Subsection (g) (other than paragraphs (3) through (5)) 
and subsections (h), (i), and (l) apply to a health care 
practitioner for purposes of this subsection to the same extent 
and in the same manner as such subsections apply to an officer, 
governing board member, employee, or contractor of an entity 
described in subsection (g)(4), subject to paragraph (6) and 
subject to the following:
          (A) The first sentence of paragraph (1) applies in 
        lieu of the first sentence of subsection (g)(1)(A).
          (B) This subsection may not be construed as deeming 
        any free clinic to be an employee of the Public Health 
        Service for purposes of this section.
          (C) With respect to a free clinic, a health care 
        practitioner is not a free clinic health professional 
        unless the free clinic sponsors the health care 
        practitioner. For purposes of this subsection, the free 
        clinic shall be considered to be sponsoring the health 
        care practitioner if--
                  (i) with respect to the health care 
                practitioner, the free clinic submits to the 
                Secretary an application meeting the 
                requirements of subsection (g)(1)(D); and
                  (ii) the Secretary, pursuant to subsection 
                (g)(1)(E), determines that the health care 
                practitioner is deemed to be an employee of the 
                Public Health Service.
          (D) In the case of a health care practitioner who is 
        determined by the Secretary pursuant to subsection 
        (g)(1)(E) to be a free clinic health professional, this 
        subsection applies to the health care practitioner 
        (with respect to the free clinic sponsoring the health 
        care practitioner pursuant to subparagraph (C)) for any 
        cause of action arising from an act or omission of the 
        health care practitioner occurring on or after the date 
        on which the Secretary makes such determination.
          (E) Subsection (g)(1)(F) applies to a health care 
        practitioner for purposes of this subsection only to 
        the extent that, in providing health services to an 
        individual, each of the conditions specified in 
        paragraph (2) is met.
  (6)(A) For purposes of making payments for judgments against 
the United States (together with related fees and expenses of 
witnesses) pursuant to this section arising from the acts or 
omissions of free clinic health professionals, there is 
authorized to be appropriated $10,000,000 for each fiscal year.
  (B) The Secretary shall establish a fund for purposes of this 
subsection. Each fiscal year amounts appropriated under 
subparagraph (A) shall be deposited in such fund.
  (C) Not later than May 1 of each fiscal year, the Attorney 
General, in consultation with the Secretary, shall submit to 
the Congress a report providing an estimate of the amount of 
claims (together with related fees and expenses of witnesses) 
that, by reason of the acts or omissions of free clinic health 
professionals, will be paid pursuant to this section during the 
calendar year that begins in the following fiscal year. 
Subsection (k)(1)(B) applies to the estimate under the 
preceding sentence regarding free clinic health professionals 
to the same extent and in the same manner as such subsection 
applies to the estimate under such subsection regarding 
officers, governing board members, employees, and contractors 
of entities described in subsection (g)(4).
  (D) Not later than December 31 of each fiscal year, the 
Secretary shall transfer from the fund under subparagraph (B) 
to the appropriate accounts in the Treasury an amount equal to 
the estimate made under subparagraph (C) for the calendar year 
beginning in such fiscal year, subject to the extent of amounts 
in the fund.
  (7)(A) This subsection takes effect on the date of the 
enactment of the first appropriations Act that makes an 
appropriation under paragraph (6)(A), except as provided in 
subparagraph (B)(i).
  (B)(i) Effective on the date of the enactment of the Health 
Insurance Portability and Accountability Act of 1996--
          (I) the Secretary may issue regulations for carrying 
        out this subsection, and the Secretary may accept and 
        consider applications submitted pursuant to paragraph 
        (5)(C); and
          (II) reports under paragraph (6)(C) may be submitted 
        to the Congress.
  (ii) For the first fiscal year for which an appropriation is 
made under subparagraph (A) of paragraph (6), if an estimate 
under subparagraph (C) of such paragraph has not been made for 
the calendar year beginning in such fiscal year, the transfer 
under subparagraph (D) of such paragraph shall be made 
notwithstanding the lack of the estimate, and the transfer 
shall be made in an amount equal to the amount of such 
appropriation.
  (p) Administration of Smallpox Countermeasures by Health 
Professionals.--
          (1) In general.--For purposes of this section, and 
        subject to other provisions of this subsection, a 
        covered person shall be deemed to be an employee of the 
        Public Health Service with respect to liability arising 
        out of administration of a covered countermeasure 
        against smallpox to an individual during the effective 
        period of a declaration by the Secretary under 
        paragraph (2)(A).
          (2) Declaration by secretary concerning 
        countermeasure against smallpox.--
                  (A) Authority to issue declaration.--
                          (i) In general.--The Secretary may 
                        issue a declaration, pursuant to this 
                        paragraph, concluding that an actual or 
                        potential bioterrorist incident or 
                        other actual or potential public health 
                        emergency makes advisable the 
                        administration of a covered 
                        countermeasure to a category or 
                        categories of individuals.
                          (ii) Covered countermeasure.--The 
                        Secretary shall specify in such 
                        declaration the substance or substances 
                        that shall be considered covered 
                        countermeasures (as defined in 
                        paragraph (7)(A)) for purposes of 
                        administration to individuals during 
                        the effective period of the 
                        declaration.
                          (iii) Effective period.--The 
                        Secretary shall specify in such 
                        declaration the beginning and ending 
                        dates of the effective period of the 
                        declaration, and may subsequently amend 
                        such declaration to shorten or extend 
                        such effective period, provided that 
                        the new closing date is after the date 
                        when the declaration is amended.
                          (iv) Publication.--The Secretary 
                        shall promptly publish each such 
                        declaration and amendment in the 
                        Federal Register.
                  (B) Liability of united states only for 
                administrations within scope of declaration.--
                Except as provided in paragraph (5)(B)(ii), the 
                United States shall be liable under this 
                subsection with respect to a claim arising out 
                of the administration of a covered 
                countermeasure to an individual only if--
                          (i) the countermeasure was 
                        administered by a qualified person, for 
                        a purpose stated in paragraph 
                        (7)(A)(i), and during the effective 
                        period of a declaration by the 
                        Secretary under subparagraph (A) with 
                        respect to such countermeasure; and
                          (ii)(I) the individual was within a 
                        category of individuals covered by the 
                        declaration; or
                          (II) the qualified person 
                        administering the countermeasure had 
                        reasonable grounds to believe that such 
                        individual was within such category.
                  (C) Presumption of administration within 
                scope of declaration in case of accidental 
                vaccinia inoculation.--
                          (i) In general.--If vaccinia vaccine 
                        is a covered countermeasure specified 
                        in a declaration under subparagraph 
                        (A), and an individual to whom the 
                        vaccinia vaccine is not administered 
                        contracts vaccinia, then, under the 
                        circumstances specified in clause (ii), 
                        the individual--
                                  (I) shall be rebuttably 
                                presumed to have contracted 
                                vaccinia from an individual to 
                                whom such vaccine was 
                                administered as provided by 
                                clauses (i) and (ii) of 
                                subparagraph (B); and
                                  (II) shall (unless such 
                                presumption is rebutted) be 
                                deemed for purposes of this 
                                subsection to be an individual 
                                to whom a covered 
                                countermeasure was administered 
                                by a qualified person in 
                                accordance with the terms of 
                                such declaration and as 
                                described by subparagraph (B).
                          (ii) Circumstances in which 
                        presumption applies.--The presumption 
                        and deeming stated in clause (i) shall 
                        apply if--
                                  (I) the individual contracts 
                                vaccinia during the effective 
                                period of a declaration under 
                                subparagraph (A) or by the date 
                                30 days after the close of such 
                                period; or
                                  (II) the individual has 
                                resided with, or has had 
                                contact with, an individual to 
                                whom such vaccine was 
                                administered as provided by 
                                clauses (i) and (ii) of 
                                subparagraph (B) and contracts 
                                vaccinia after such date.
                  (D) Acts and omissions deemed to be within 
                scope of employment.--
                          (i) In general.--In the case of a 
                        claim arising out of alleged 
                        transmission of vaccinia from an 
                        individual described in clause (ii), 
                        acts or omissions by such individual 
                        shall be deemed to have been taken 
                        within the scope of such individual's 
                        office or employment for purposes of--
                                  (I) subsection (a); and
                                  (II) section 1346(b) and 
                                chapter 171 of title 28, United 
                                States Code.
                          (ii) Individuals to whom deeming 
                        applies.--An individual is described by 
                        this clause if--
                                  (I) vaccinia vaccine was 
                                administered to such individual 
                                as provided by subparagraph 
                                (B); and
                                  (II) such individual was 
                                within a category of 
                                individuals covered by a 
                                declaration under subparagraph 
                                (A)(i).
          (3) Exhaustion; exclusivity; offset.--
                  (A) Exhaustion.--
                          (i) In general.--A person may not 
                        bring a claim under this subsection 
                        unless such person has exhausted such 
                        remedies as are available under part C 
                        of this title, except that if the 
                        Secretary fails to make a final 
                        determination on a request for benefits 
                        or compensation filed in accordance 
                        with the requirements of such part 
                        within 240 days after such request was 
                        filed, the individual may seek any 
                        remedy that may be available under this 
                        section.
                          (ii) Tolling of statute of 
                        limitations.--The time limit for filing 
                        a claim under this subsection, or for 
                        filing an action based on such claim, 
                        shall be tolled during the pendency of 
                        a request for benefits or compensation 
                        under part C of this title.
                          (iii) Construction.--This subsection 
                        shall not be construed as superseding 
                        or otherwise affecting the application 
                        of a requirement, under chapter 171 of 
                        title 28, United States Code, to 
                        exhaust administrative remedies.
                  (B) Exclusivity.--The remedy provided by 
                subsection (a) shall be exclusive of any other 
                civil action or proceeding for any claim or 
                suit this subsection encompasses, except for a 
                proceeding under part C of this title.
                  (C) Offset.--The value of all compensation 
                and benefits provided under part C of this 
                title for an incident or series of incidents 
                shall be offset against the amount of an award, 
                compromise, or settlement of money damages in a 
                claim or suit under this subsection based on 
                the same incident or series of incidents.
          (4) Certification of action by attorney general.--
        Subsection (c) applies to actions under this 
        subsection, subject to the following provisions:
                  (A) Nature of certification.--The 
                certification by the Attorney General that is 
                the basis for deeming an action or proceeding 
                to be against the United States, and for 
                removing an action or proceeding from a State 
                court, is a certification that the action or 
                proceeding is against a covered person and is 
                based upon a claim alleging personal injury or 
                death arising out of the administration of a 
                covered countermeasure.
                  (B) Certification of attorney general 
                conclusive.--The certification of the Attorney 
                General of the facts specified in subparagraph 
                (A) shall conclusively establish such facts for 
                purposes of jurisdiction pursuant to this 
                subsection.
          (5) Covered person to cooperate with united states.--
                  (A) In general.--A covered person shall 
                cooperate with the United States in the 
                processing and defense of a claim or action 
                under this subsection based upon alleged acts 
                or omissions of such person.
                  (B) Consequences of failure to cooperate.--
                Upon the motion of the United States or any 
                other party and upon finding that such person 
                has failed to so cooperate--
                          (i) the court shall substitute such 
                        person as the party defendant in place 
                        of the United States and, upon motion, 
                        shall remand any such suit to the court 
                        in which it was instituted if it 
                        appears that the court lacks subject 
                        matter jurisdiction;
                          (ii) the United States shall not be 
                        liable based on the acts or omissions 
                        of such person; and
                          (iii) the Attorney General shall not 
                        be obligated to defend such action.
          (6) Recourse against covered person in case of gross 
        misconduct or contract violation.--
                  (A) In general.--Should payment be made by 
                the United States to any claimant bringing a 
                claim under this subsection, either by way of 
                administrative determination, settlement, or 
                court judgment, the United States shall have, 
                notwithstanding any provision of State law, the 
                right to recover for that portion of the 
                damages so awarded or paid, as well as interest 
                and any costs of litigation, resulting from the 
                failure of any covered person to carry out any 
                obligation or responsibility assumed by such 
                person under a contract with the United States 
                or from any grossly negligent, reckless, or 
                illegal conduct or willful misconduct on the 
                part of such person.
                  (B) Venue.--The United States may maintain an 
                action under this paragraph against such person 
                in the district court of the United States in 
                which such person resides or has its principal 
                place of business.
          (7) Definitions.--As used in this subsection, terms 
        have the following meanings:
                  (A) Covered countermeasure.--The term 
                ``covered countermeasure'' or ``covered 
                countermeasure against smallpox'', means a 
                substance that is--
                          (i)(I) used to prevent or treat 
                        smallpox (including the vaccinia or 
                        another vaccine); or
                                  (II) used to control or treat 
                                the adverse effects of vaccinia 
                                inoculation or of 
                                administration of another 
                                covered countermeasure; and
                          (ii) specified in a declaration under 
                        paragraph (2).
                  (B) Covered person.--The term ``covered 
                person'', when used with respect to the 
                administration of a covered countermeasure, 
                means a person who is--
                          (i) a manufacturer or distributor of 
                        such countermeasure;
                          (ii) a health care entity under whose 
                        auspices--
                                  (I) such countermeasure was 
                                administered;
                                  (II) a determination was made 
                                as to whether, or under what 
                                circumstances, an individual 
                                should receive a covered 
                                countermeasure;
                                  (III) the immediate site of 
                                administration on the body of a 
                                covered countermeasure was 
                                monitored, managed, or cared 
                                for; or
                                  (IV) an evaluation was made 
                                of whether the administration 
                                of a countermeasure was 
                                effective;
                          (iii) a qualified person who 
                        administered such countermeasure;
                          (iv) a State, a political subdivision 
                        of a State, or an agency or official of 
                        a State or of such a political 
                        subdivision, if such State, 
                        subdivision, agency, or official has 
                        established requirements, provided 
                        policy guidance, supplied technical or 
                        scientific advice or assistance, or 
                        otherwise supervised or administered a 
                        program with respect to administration 
                        of such countermeasures;
                          (v) in the case of a claim arising 
                        out of alleged transmission of vaccinia 
                        from an individual--
                                  (I) the individual who 
                                allegedly transmitted the 
                                vaccinia, if vaccinia vaccine 
                                was administered to such 
                                individual as provided by 
                                paragraph (2)(B) and such 
                                individual was within a 
                                category of individuals covered 
                                by a declaration under 
                                paragraph (2)(A)(i); or
                                  (II) an entity that employs 
                                an individual described by 
                                clause (I) or where such 
                                individual has privileges or is 
                                otherwise authorized to provide 
                                health care;
                          (vi) an official, agent, or employee 
                        of a person described in clause (i), 
                        (ii), (iii), or (iv);
                          (vii) a contractor of, or a volunteer 
                        working for, a person described in 
                        clause (i), (ii), or (iv), if the 
                        contractor or volunteer performs a 
                        function for which a person described 
                        in clause (i), (ii), or (iv) is a 
                        covered person; or
                          (viii) an individual who has 
                        privileges or is otherwise authorized 
                        to provide health care under the 
                        auspices of an entity described in 
                        clause (ii) or (v)(II).
                  (C) Qualified person.--The term ``qualified 
                person'', when used with respect to the 
                administration of a covered countermeasure, 
                means a licensed health professional or other 
                individual who--
                          (i) is authorized to administer such 
                        countermeasure under the law of the 
                        State in which the countermeasure was 
                        administered; or
                          (ii) is otherwise authorized by the 
                        Secretary to administer such 
                        countermeasure.
                  (D) Arising out of administration of a 
                covered countermeasure.--The term ``arising out 
                of administration of a covered 
                countermeasure'', when used with respect to a 
                claim or liability, includes a claim or 
                liability arising out of--
                          (i) determining whether, or under 
                        what conditions, an individual should 
                        receive a covered countermeasure;
                          (ii) obtaining informed consent of an 
                        individual to the administration of a 
                        covered countermeasure;
                          (iii) monitoring, management, or care 
                        of an immediate site of administration 
                        on the body of a covered 
                        countermeasure, or evaluation of 
                        whether the administration of the 
                        countermeasure has been effective; or
                          (iv) transmission of vaccinia virus 
                        by an individual to whom vaccinia 
                        vaccine was administered as provided by 
                        paragraph (2)(B).
  (q)(1) For purposes of this section, a health professional 
volunteer at a deemed entity described in subsection (g)(4) 
shall, in providing a health professional service eligible for 
funding under section 330 to an individual, be deemed to be an 
employee of the Public Health Service for a calendar year that 
begins during a fiscal year for which a transfer was made under 
paragraph (4)(C). The preceding sentence is subject to the 
provisions of this subsection.
  (2) In providing a health service to an individual, a health 
care practitioner shall for purposes of this subsection be 
considered to be a health professional volunteer at an entity 
described in subsection (g)(4) if the following conditions are 
met:
          (A) The service is provided to the individual at the 
        facilities of an entity described in subsection (g)(4), 
        or through offsite programs or events carried out by 
        the entity.
          (B) The entity is sponsoring the health care 
        practitioner pursuant to paragraph (3)(B).
          (C) The health care practitioner does not receive any 
        compensation for the service from the individual, the 
        entity described in subsection (g)(4), or any third-
        party payer (including reimbursement under any 
        insurance policy or health plan, or under any Federal 
        or State health benefits program), except that the 
        health care practitioner may receive repayment from the 
        entity described in subsection (g)(4) for reasonable 
        expenses incurred by the health care practitioner in 
        the provision of the service to the individual, which 
        may include travel expenses to or from the site of 
        services.
          (D) Before the service is provided, the health care 
        practitioner or the entity described in subsection 
        (g)(4) posts a clear and conspicuous notice at the site 
        where the service is provided of the extent to which 
        the legal liability of the health care practitioner is 
        limited pursuant to this subsection.
          (E) At the time the service is provided, the health 
        care practitioner is licensed or certified in 
        accordance with applicable Federal and State laws 
        regarding the provision of the service.
          (F) At the time the service is provided, the entity 
        described in subsection (g)(4) maintains relevant 
        documentation certifying that the health care 
        practitioner meets the requirements of this subsection.
  (3) Subsection (g) (other than paragraphs (3) and (5)) and 
subsections (h), (i), and (l) apply to a health care 
practitioner for purposes of this subsection to the same extent 
and in the same manner as such subsections apply to an officer, 
governing board member, employee, or contractor of an entity 
described in subsection (g)(4), subject to paragraph (4), and 
subject to the following:
          (A) The first sentence of paragraph (1) applies in 
        lieu of the first sentence of subsection (g)(1)(A).
          (B) With respect to an entity described in subsection 
        (g)(4), a health care practitioner is not a health 
        professional volunteer at such entity unless the entity 
        sponsors the health care practitioner. For purposes of 
        this subsection, the entity shall be considered to be 
        sponsoring the health care practitioner if--
                  (i) with respect to the health care 
                practitioner, the entity submits to the 
                Secretary an application meeting the 
                requirements of subsection (g)(1)(D); and
                  (ii) the Secretary, pursuant to subsection 
                (g)(1)(E), determines that the health care 
                practitioner is deemed to be an employee of the 
                Public Health Service.
          (C) In the case of a health care practitioner who is 
        determined by the Secretary pursuant to subsection 
        (g)(1)(E) to be a health professional volunteer at such 
        entity, this subsection applies to the health care 
        practitioner (with respect to services performed on 
        behalf of the entity sponsoring the health care 
        practitioner pursuant to subparagraph (B)) for any 
        cause of action arising from an act or omission of the 
        health care practitioner occurring on or after the date 
        on which the Secretary makes such determination.
          (D) Subsection (g)(1)(F) applies to a health care 
        practitioner for purposes of this subsection only to 
        the extent that, in providing health services to an 
        individual, each of the conditions specified in 
        paragraph (2) is met.
  (4)(A) Amounts in the fund established under subsection 
(k)(2) shall be available for transfer under subparagraph (C) 
for purposes of carrying out this subsection.
  (B)(i) Not later than May 1 of each fiscal year, the Attorney 
General, in consultation with the Secretary, shall submit to 
the Congress a report providing an estimate of the amount of 
claims (together with related fees and expenses of witnesses) 
that, by reason of the acts or omissions of health professional 
volunteers, will be paid pursuant to this section during the 
calendar year that begins in the following fiscal year.
  (ii) Subsection (k)(1)(B) applies to the estimate under 
clause (i) regarding health professional volunteers to the same 
extent and in the same manner as such subsection applies to the 
estimate under such subsection regarding officers, governing 
board members, employees, and contractors of entities described 
in subsection (g)(4).
  (iii) The report shall include a summary of the data relied 
upon for the estimate in clause (i), including the number of 
claims filed and paid from the previous calendar year.
  (C) Not later than December 31 of each fiscal year, the 
Secretary shall transfer from the fund under subsection (k)(2) 
to the appropriate accounts in the Treasury an amount equal to 
the estimate made under subparagraph (B) for the calendar year 
beginning in such fiscal year, subject to the extent of amounts 
in the fund.
  (5)(A) This subsection shall take effect on October 1, 2017, 
except as provided in subparagraph (B) and paragraph (6).
  (B) Effective on the date of the enactment of this 
subsection--
          (i) the Secretary may issue regulations for carrying 
        out this subsection, and the Secretary may accept and 
        consider applications submitted pursuant to paragraph 
        (3)(B); and
          (ii) reports under paragraph (4)(B) may be submitted 
        to Congress.
  (6) Beginning on October 1, 2022, this subsection shall cease 
to have any force or effect.
  (r) Certain Indian Health Service Volunteers Deemed Public 
Health Service Employees.--
          (1) In general.--For purposes of this section, an 
        employee of an IHS urban Indian health program and a 
        health professional volunteer at a Service unit shall, 
        in providing a health service to an individual, be 
        deemed to be an employee of the Public Health Service 
        for a calendar year that begins during a fiscal year 
        for which a transfer was made under paragraph (4)(C). 
        The preceding sentence is subject to the provisions of 
        this subsection.
          (2) Conditions.--In providing a health service to an 
        individual, a health care practitioner shall, for 
        purposes of this subsection, be considered to be a 
        health professional volunteer at a Service unit if all 
        of the following conditions are met:
                  (A) The service is provided to the individual 
                at the facilities of a Service unit, or through 
                offsite programs or events carried out by the 
                Service unit.
                  (B) The Service unit is sponsoring the health 
                care practitioner pursuant to paragraph (3)(C).
                  (C) The health care practitioner does not 
                receive any compensation for the service from 
                the individual, the Service unit, or any third-
                party payer (including reimbursement under any 
                insurance policy or health plan, or under any 
                Federal or State health benefits program), 
                except that the health care practitioner may 
                receive repayment from the Service unit for 
                reasonable expenses incurred by the health care 
                practitioner in the provision of the service to 
                the individual.
                  (D) Before the service is provided, the 
                health care practitioner or the Service unit 
                posts a clear and conspicuous notice at the 
                site where the service is provided of the 
                extent to which the legal liability of the 
                health care practitioner is limited under this 
                subsection.
                  (E) At the time the service is provided, the 
                health care practitioner is licensed, 
                certified, credentialed, and privileged in 
                accordance with Service policy and applicable 
                law regarding the provision of the service.
          (3) Applicability.--Subsection (g) (other than 
        paragraphs (3) and (5)) and subsections (h), (i), and 
        (l) apply to an employee of an IHS urban Indian health 
        program and to a health care practitioner at a Service 
        unit for purposes of this subsection to the same extent 
        and in the same manner as such subsections apply to an 
        officer, governing board member, employee, or 
        contractor of an entity described in subsection (g)(4), 
        subject to paragraph (4) and subject to the following 
        subparagraphs:
                  (A) Each reference to an entity in 
                subsections (g), (h), (i), and (l) shall be 
                considered to be a reference to an IHS urban 
                Indian health program or a Service unit, as 
                applicable.
                  (B) The first sentence of paragraph (1) 
                applies in lieu of the first sentence of 
                subsection (g)(1)(A).
                  (C) With respect to a Service unit, a health 
                care practitioner is not a health professional 
                volunteer at the Service unit unless the 
                Service unit sponsors the health care 
                practitioner. For purposes of this subsection, 
                the Service unit shall be considered to be 
                sponsoring the health care practitioner if--
                          (i) with respect to the health care 
                        practitioner, the Service unit submits 
                        to the Secretary an application meeting 
                        the requirements of subsection 
                        (g)(1)(D); and
                          (ii) the Secretary, pursuant to 
                        subsection (g)(1)(E), determines that 
                        the health care practitioner is deemed 
                        to be an employee of the Public Health 
                        Service.
                  (D) In the case of a health care practitioner 
                who is determined by the Secretary pursuant to 
                this subsection and subsection (g)(1)(E) to be 
                a health professional volunteer, this 
                subsection applies to the health care 
                practitioner (with respect to services 
                performed on behalf of the Service unit 
                sponsoring the health care practitioner 
                pursuant to subparagraph (C)) for any cause of 
                action arising from an act or omission of the 
                health care practitioner occurring on or after 
                the date on which the Secretary makes that 
                determination.
                  (E) Subsection (g)(1)(F) applies to a health 
                care practitioner for purposes of this 
                subsection only to the extent that, in 
                providing health services to an individual, 
                each of the conditions described in paragraph 
                (2) is met.
          (4) Funding.--
                  (A) In general.--Amounts in the fund 
                established under subsection (k)(2) shall be 
                available for transfer under subparagraph (C) 
                for purposes of carrying out this subsection.
                  (B) Annual estimates.--
                          (i) In general.--Not later than May 1 
                        of each fiscal year, the Attorney 
                        General, in consultation with the 
                        Secretary, shall submit to Congress a 
                        report providing an estimate of the 
                        amount of claims (together with related 
                        fees and expenses of witnesses) that, 
                        by reason of the acts or omissions of 
                        employees of an IHS urban Indian health 
                        program or health professional 
                        volunteers, will be paid pursuant to 
                        this section during the calendar year 
                        that begins in the following fiscal 
                        year.
                          (ii) Applicability.--Subsection 
                        (k)(1)(B) applies to the estimate under 
                        clause (i) relating to employees of an 
                        IHS urban Indian health program or 
                        health professional volunteers to the 
                        same extent and in the same manner as 
                        that subsection applies to the estimate 
                        under that subsection relating to 
                        officers, governing board members, 
                        employees, and contractors of entities 
                        described in subsection (g)(4).
                  (C) Transfers.--Not later than December 31 of 
                each fiscal year, the Secretary shall transfer 
                from the fund under subsection (k)(2) to the 
                appropriate accounts in the Treasury an amount 
                equal to the estimate made under subparagraph 
                (B) for the calendar year beginning in that 
                fiscal year, subject to the extent of amounts 
                in the fund.
          (5) Definitions.--
                  (A) IHS urban indian health program.--In this 
                subsection, the term ``IHS urban Indian health 
                program'' means an urban Indian health program 
                operated by an urban Indian organization 
                pursuant to a grant or contract with the Indian 
                Health Service under title V of the Indian 
                Health Care Improvement Act (25 U.S.C. 1651 et 
                seq.).
                  (B) Service unit.--In this subsection, the 
                term ``Service unit'' has the meaning given the 
                term in section 4 of the Indian Health Care 
                Improvement Act (25 U.S.C. 1603).
          (6) Rule of construction.--Nothing in this subsection 
        may be construed--
                  (A) to negatively impact the right of an 
                Indian Tribe to enter into a compact or 
                contract under the Indian Self-Determination 
                and Education Assistance Act (25 U.S.C. 5304 et 
                seq.); and
                  (B) to apply to such a compact or contract 
                unless expressly agreed to by the Indian Tribe.
          (7) Effective dates.--
                  (A) In general.--Except as provided in 
                subparagraph (B), this subsection shall take 
                effect on October 1, 2019.
                  (B) Regulations, applications, and reports.--
                Effective on the date of the enactment of the 
                Restoring Accountability in the Indian Health 
                Service Act of 2018, the Secretary may--
                          (i) prescribe regulations for 
                        carrying out this subsection; and
                          (ii) accept and consider applications 
                        submitted under paragraph (3)(C)(i).

           *       *       *       *       *       *       *

                              ----------                              


                        ACT OF DECEMBER 15, 1979



           *       *       *       *       *       *       *
SEC. 2. (A) FOR PURPOSES OF APPLYING REDUCTION-IN-FORCE PROCEDURES 
                    REDUCTIONS IN UNDER SUBSECTION (A) OF SECTION 3502 
                    OF TITLE 5, UNITED STATES CODE, WITH RESPECT TO 
                    POSITIONS WITHIN THE BUREAU OF INDIAN AFFAIRS AND 
                    THE INDIAN HEALTH SERVICE, THE COMPETITIVE AND 
                    EXCEPTED SERVICE RETENTION REGISTERS SHALL BE 
                    COMBINED, AND ANY EMPLOYEE ENTITLED TO INDIAN 
                    PREFERENCE WHO IS WITHIN A RETENTION CATEGORY 
                    ESTABLISHED UNDER REGULATIONS PRESCRIBED UNDER SUCH 
                    SUBSECTION TO PROVIDE DUE EFFECT TO MILITARY 
                    PREFERENCE SHALL BE ENTITLED TO BE RETAINED IN 
                    PREFERENCE TO OTHER EMPLOYEES NOT ENTITLED TO 
                    INDIAN PREFERENCE WHO ARE WITHIN SUCH RETENTION 
                    CATEGORY.

  (b)(1) The Indian preference laws shall not apply in the case 
of any reassignment within the Bureau of Indian Affairs or 
within the Indian Health Service (other than to a position in a 
higher grade) of an employee not entitled to Indian preference 
if it is determined that under the circumstances such 
reassignment is necessary--
          (A) to assure the health or safety of the employee or 
        of any member of the employee's household;
          (B) in the course of a reduction in force; or
          (C) because the employee's working relationship with 
        a tribe has so deteriorated that the employee cannot 
        provide effective service for such tribe or the Federal 
        Government.
  (2) The authority to make any determination under 
subparagraph (A), (B), or (C) of paragraph (1) is vested in the 
Secretary of the Interior with respect to the Bureau of Indian 
Affairs and the Secretary of Health, Education, and Welfare 
with respect to the Indian Health Service, and, notwithstanding 
any other provision of law, the Secretary involved may not 
delegate such authority to any individual other than an Under 
Secretary or Assistant Secretary of the respective department.
  (c)(1) Notwithstanding any provision of the Indian preference 
laws, such laws shall not apply in the case of any personnel 
action respecting an applicant or employee not entitled to 
Indian preference if each tribal organization concerned grants, 
in writing, a waiver of the application of such laws with 
respect to such personnel action.
  (2) The provisions of section 8336Q) of title 5, United 
States Code (as added by the preceding section of this Act), 
shall not apply to any individual who has accepted a waiver 
with respect to a personnel action pursuant to paragraph (1) of 
this subsection or to section 1131(f) of the Education 
Amendments of 1978 (25 U.S.C. 20110; 92 Stat. 2324).
          (3) IHS waivers.--The Secretary of Health and Human 
        Services may, at the request of an Indian Tribe, seek 
        from each Indian Tribe concerned, a waiver of Indian 
        preference laws for a personnel action that is with 
        respect to--
                  (A) an Indian Health Service unit in which 15 
                percent or more of the total positions or 
                specific health professionals in the Service 
                unit are not filled by a full-time employee of 
                the Indian Health Service for a period of 6 
                months or longer; or
                  (B) a former employee of the Indian Health 
                Service or a former tribal employee who was 
                removed from such former employment within, or 
                demoted for performance or misconduct that 
                occurred during, the 5-year period following 
                the date of such personnel action.
  (d) The Office of Personnel Management shall provide all 
appropriate assistance to the Bureau of Indian Affairs and the 
Indian Health Service in placing non-Indian employees of such 
agencies in other Federal positions. All other Federal agencies 
shall cooperate to the fullest extent possible in such 
placement efforts.
  (e) For purposes of this section--
          (1) The term ``tribal organization'' means--
                  (A) the recognized governing body of any 
                Indian tribe, band, nation, pueblo, or other 
                organized community, including a Native village 
                (as defined in section 3(c) of the Alaska 
                Native Claims Settlement Act (43 U.S.C. 
                1602(c); 85 Stat. 688)); or
                  (B) in connection with any personnel action 
                referred to in subsection (c)(l) of this 
                section, any legally established organization 
                of Indians which is controlled, sanctioned, or 
                chartered by a governing M y referred to in 
                subparagraph (A) of this paragraph and which 
                has been delegated by such governing body the 
                authority to grant a waiver under such 
                subsection with respect to such personnel 
                action.
          (3) The term ``Bureau of Indian Affairs'' means (A) 
        the Bureau of Indian Affairs and (B) all other 
        organizational units in the Department of the Interior 
        directly and primarily related to providing services to 
        Indians an4 in which positions are filled in accordance 
        with the Indian preference laws.
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                      TITLE 5, UNITED STATES CODE



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PART III--EMPLOYEES

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SUBPART C--EMPLOYEE PERFORMANCE

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CHAPTER 43--PERFORMANCE APPRAISAL

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SUBCHAPTER I--GENERAL PROVISIONS

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Sec. 4303. Actions based on unacceptable performance

  (a) Subject to the provisions of this section, an agency may 
reduce in grade or remove an employee for unacceptable 
performance.
  (b)(1) An employee whose reduction in grade or removal is 
proposed under this section is entitled to--
          (A) 30 days' advance written notice of the proposed 
        action which identifies--
                  (i) specific instances of unacceptable 
                performance by the employee on which the 
                proposed action is based; and
                  (ii) the critical elements of the employee's 
                position involved in each instance of 
                unacceptable performance;
          (B) be represented by an attorney or other 
        representative;
          (C) a reasonable time to answer orally and in 
        writing; and
          (D) a written decision which--
                  (i) in the case of a reduction in grade or 
                removal under this section, specifies the 
                instances of unacceptable performance by the 
                employee on which the reduction in grade or 
                removal is based, and
                  (ii) unless proposed by the head of the 
                agency, has been concurred in by an employee 
                who is in a higher position than the employee 
                who proposed the action.
  (2) An agency may, under regulations prescribed by the head 
of such agency, extend the notice period under subsection 
(b)(1)(A) of this section for not more than 30 days. An agency 
may extend the notice period for more than 30 days only in 
accordance with regulations issued by the Office of Personnel 
Management.
  (c) The decision to retain, reduce in grade, or remove an 
employee--
          (1) shall be made within 30 days after the date of 
        expiration of the notice period, and
          (2) in the case of a reduction in grade or removal, 
        may be based only on those instances of unacceptable 
        performance by the employee--
                  (A) which occurred during the 1-year period 
                ending on the date of the notice under 
                subsection (b)(1)(A) of this section in 
                connection with the decision; and
                  (B) for which the notice and other 
                requirements of this section are complied with.
  (d) If, because of performance improvement by the employee 
during the notice period, the employee is not reduced in grade 
or removed, and the employee's performance continues to be 
acceptable for 1 year from the date of the advance written 
notice provided under subsection (b)(1)(A) of this section, any 
entry or other notation of the unacceptable performance for 
which the action was proposed under this section shall be 
removed from any agency record relating to the employee.
  (e) Any employee who is--
          (1) a preference eligible;
          (2) in the competitive service; or
          (3) in the excepted service and covered by subchapter 
        II of chapter 75,
and who has been reduced in grade or removed under this section 
is entitled to appeal the action to the Merit Systems 
Protection Board under section 7701.
  (f) This section does not apply to--
          (1) the reduction to the grade previously held of a 
        supervisor or manager who has not completed the 
        probationary period under section 3321(a)(2) of this 
        title,
          (2) the reduction in grade or removal of an employee 
        in the competitive service who is serving a 
        probationary or trial period under an initial 
        appointment or who has not completed 1 year of current 
        continuous employment under other than a temporary 
        appointment limited to 1 year or less,
          (3) the reduction in grade or removal of an employee 
        in the excepted service who has not completed 1 year of 
        current continuous employment in the same or similar 
        positions, [or]
          (4) any removal or demotion under section 714 of 
        title 38[.], or
          (5) any removal or demotion under section 607 of the 
        Indian Health Care Improvement Act.

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SUBPART F--LABOR-MANAGEMENT AND EMPLOYEE RELATIONS

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CHAPTER 72--ANTIDISCRIMINATION; RIGHT TO PETITION CONGRESS

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          SUBCHAPTER II--EMPLOYEES' RIGHT TO PETITION CONGRESS

Sec. 7211. Employees' right to petition Congress

   [The right of] (a) In General._The right of  employees, 
individually or collectively, to petition Congress or a Member 
of Congress, or to furnish information to either House of 
Congress, or to a committee or Member thereof, may not be 
interfered with or denied.
  (b) Adverse Action.--An employee who interferes with or 
denies a right protected under subsection (a) shall be subject 
to any adverse action described in paragraphs (1) through (5) 
of section 7512, in accordance with the procedure described in 
section 7513 and any other applicable procedure.
                              ----------                              


                          SOCIAL SECURITY ACT



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TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED

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Part E--Miscellaneous Provisions

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                    indian health service facilities

  Sec. 1880. (a) A hospital or skilled nursing facility of the 
Indian Health Service, whether operated by such Service or by 
an Indian tribe or tribal organization (as those terms are 
defined in section 4 of the Indian Health Care Improvement 
Act), shall be eligible for payments under this title, 
notwithstanding sections 1814(c) and 1835(d), if and for so 
long as it meets all of the conditions and requirements for 
such payments which are applicable generally to hospitals or 
skilled nursing facilities (as the case may be) under this 
title.
  (b) Notwithstanding subsection (a), a hospital or skilled 
nursing facility of the Indian Health Service which does not 
meet all of the conditions and requirements of this title which 
are applicable generally to hospitals or skilled nursing 
facilities (as the case may be), but which submits to the 
Secretary within six months after the date of the enactment of 
this section an acceptable plan for achieving compliance with 
such conditions and requirements, shall be deemed to meet such 
conditions and requirements (and to be eligible for payments 
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.
  (c) Notwithstanding any other provision of this title, 
payments to which any hospital or skilled nursing facility of 
the Indian Health Service is entitled by reason of this section 
shall be placed in a special fund to be held by the Secretary 
and used by him (to such extent or in such amounts as are 
provided in appropriation Acts) exclusively for the purpose of 
making any improvements in the hospitals and skilled nursing 
facilities of such Service which may be necessary to achieve 
compliance with the applicable conditions and requirements of 
this title. The preceding sentence shall cease to apply when 
the Secretary determines and certifies that substantially all 
of the hospitals and skilled nursing facilities of such Service 
in the United States are in compliance with such conditions and 
requirements.
  (d) The annual report of the Secretary which is required by 
section 701 of the Indian Health Care Improvement Act shall 
include (along with the matters specified in section 403 of 
such Act) a detailed statement of the status of the hospitals 
and skilled nursing facilities of the Service in terms of their 
compliance with the applicable conditions and requirements of 
this title and of the progress being made by such hospitals and 
facilities (under plans submitted under subsection (b) and 
otherwise) toward the achievement of such compliance.
  (e)(1)(A) Notwithstanding section 1835(d), subject to 
subparagraph (B), the Secretary shall make payment under part B 
to a hospital or an ambulatory care clinic (whether provider-
based or freestanding) that is operated by the Indian Health 
Service or by an Indian tribe or tribal organization (as 
defined for purposes of subsection (a)) for services described 
in paragraph (2) (and for items and services furnished on or 
after January 1, 2005, all items and services for which payment 
may be made under part B) furnished in or at the direction of 
the hospital or clinic under the same situations, terms, and 
conditions as would apply if the services were furnished in or 
at the direction of such a hospital or clinic that was not 
operated by such Service, tribe, or organization.
  (B) Payment shall not be made for services under subparagraph 
(A) to the extent that payment is otherwise made for such 
services under this title.
  (2) The services described in this paragraph are the 
following:
          (A) Services for which payment is made under section 
        1848.
          (B) Services furnished by a practitioner described in 
        section 1842(b)(18)(C) for which payment under part B 
        is made under a fee schedule.
          (C) Services furnished by a physical therapist or 
        occupational therapist as described in section 1861(p) 
        for which payment under part B is made under a fee 
        schedule.
  (3) Subsection (c) shall not apply to payments made under 
this subsection.
  (f) For provisions relating to the authority of certain 
Indian tribes, tribal organizations, and Alaska Native health 
organizations to elect to directly bill for, and receive 
payment for, health care services provided by a hospital or 
clinic of such tribes or organizations and for which payment 
may be made under this title, see section 405 of the Indian 
Health Care Improvement Act (25 U.S.C. 1645).
  (g)(1) Not less frequently than once every 2 years, the 
Administrator of the Centers for Medicare & Medicaid Services 
shall conduct surveys of participating Indian Health Service 
facilities to assess the compliance of each hospital or skilled 
nursing facility of the Indian Health Service with--
          (A) section 1867; and
          (B) conditions of participation in the program under 
        this title.
  (2) Each survey completed under this subsection shall be 
posted on the Internet website of the Centers for Medicare & 
Medicaid Services. Such posting shall comply with the Federal 
regulations concerning the privacy of individually identifiable 
health information promulgated under section 264(c) of the 
Health Insurance Portability and Accountability Act of 1996.

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