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                                                       Calendar No. 272

106th CONGRESS

  1st Session

                                 S. 406

                          [Report No. 106-152]

_______________________________________________________________________

                                 A BILL

 To amend the Indian Health Care Improvement Act to make permanent the 
   demonstration program that allows for direct billing of medicare, 
 medicaid, and other third party payors, and to expand the eligibility 
      under such program to other tribes and tribal organizations.

_______________________________________________________________________

                           September 8, 1999

                       Reported with an amendment





                                                       Calendar No. 272
106th CONGRESS
  1st Session
                                 S. 406

                          [Report No. 106-152]

 To amend the Indian Health Care Improvement Act to make permanent the 
   demonstration program that allows for direct billing of medicare, 
 medicaid, and other third party payors, and to expand the eligibility 
      under such program to other tribes and tribal organizations.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                           February 10, 1999

   Mr. Murkowski (for himself, Mr. Lott, Mr. Baucus, Mr. Inhofe, Mr. 
   Cochran, Mr. Campbell, Mr. Inouye, and Mr. Hatch) introduced the 
 following bill; which was read twice and referred to the Committee on 
                             Indian Affairs

                           September 8, 1999

              Reported by Mr. Campbell, with an amendment
 [Strike out all after the enacting clause and insert the part printed 
                               in italic]

_______________________________________________________________________

                                 A BILL


 
 To amend the Indian Health Care Improvement Act to make permanent the 
   demonstration program that allows for direct billing of medicare, 
 medicaid, and other third party payors, and to expand the eligibility 
      under such program to other tribes and tribal organizations.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

<DELETED>SECTION 1. SHORT TITLE.</DELETED>

<DELETED>    This Act may be cited as the ``Alaska Native and American 
Indian Direct Reimbursement Act of 1999''.</DELETED>

<DELETED>SEC. 2. FINDINGS.</DELETED>

<DELETED>    Congress finds the following:</DELETED>
        <DELETED>    (1) In 1988, Congress enacted section 405 of the 
        Indian Health Care Improvement Act (25 U.S.C. 1645) that 
        established a demonstration program to authorize 4 tribally-
        operated Indian Health Service hospitals or clinics to test 
        methods for direct billing and receipt of payment for health 
        services provided to patients eligible for reimbursement under 
        the medicare or medicaid programs under titles XVIII and XIX of 
        the Social Security Act (42 U.S.C. 1395 et seq.; 1396 et seq.), 
        and other third-party payors.</DELETED>
        <DELETED>    (2) The 4 participants selected by the Indian 
        Health Service for the demonstration program began the direct 
        billing and collection program in fiscal year 1989 and 
        unanimously expressed success and satisfaction with the 
        program. Benefits of the program include dramatically increased 
        collections for services provided under the medicare and 
        medicaid programs, a significant reduction in the turn-around 
        time between billing and receipt of payments for services 
        provided to eligible patients, and increased efficiency of 
        participants being able to track their own billings and 
        collections.</DELETED>
        <DELETED>    (3) The success of the demonstration program 
        confirms that the direct involvement of tribes and tribal 
        organizations in the direct billing of, and collection of 
        payments from, the medicare and medicaid programs, and other 
        third payor reimbursements, is more beneficial to Indian tribes 
        than the current system of Indian Health Service-managed 
        collections.</DELETED>
        <DELETED>    (4) Allowing tribes and tribal organizations to 
        directly manage their medicare and medicaid billings and 
        collections, rather than channeling all activities through the 
        Indian Health Service, will enable the Indian Health Service to 
        reduce its administrative costs, is consistent with the 
        provisions of the Indian Self-Determination Act, and furthers 
        the commitment of the Secretary to enable tribes and tribal 
        organizations to manage and operate their health care 
        programs.</DELETED>
        <DELETED>    (5) The demonstration program was originally to 
        expire on September 30, 1996, but was extended by Congress, so 
        that the current participants would not experience an 
        interruption in the program while Congress awaited a 
        recommendation from the Secretary of Health and Human Services 
        on whether to make the program permanent.</DELETED>
        <DELETED>    (6) It would be beneficial to the Indian Health 
        Service and to Indian tribes, tribal organizations, and Alaska 
        Native organizations to provide permanent status to the 
        demonstration program and to extend participation in the 
        program to other Indian tribes, tribal organizations, and 
        Alaska Native health organizations who operate a facility of 
        the Indian Health Service.</DELETED>

<DELETED>SEC. 3. DIRECT BILLING OF MEDICARE, MEDICAID, AND OTHER THIRD 
              PARTY PAYORS.</DELETED>

<DELETED>    (a) Permanent Authorization.--Section 405 of the Indian 
Health Care Improvement Act (25 U.S.C. 1645) is amended to read as 
follows:</DELETED>
<DELETED>    ``(a) Establishment of Direct Billing Program.--</DELETED>
        <DELETED>    ``(1) In general.--The Secretary shall establish a 
        program under which Indian tribes, tribal organizations, and 
        Alaska Native health organizations that contract or compact for 
        the operation of a hospital or clinic of the Service under the 
        Indian Self-Determination and Education Assistance Act may 
        elect to directly bill for, and receive payment for, health 
        care services provided by such hospital or clinic for which 
        payment is made under title XVIII of the Social Security Act 
        (42 U.S.C. 1395 et seq.) (in this section referred to as the 
        `medicare program'), under a State plan for medical assistance 
        approved under title XIX of the Social Security Act (42 U.S.C. 
1396 et seq.) (in this section referred to as the `medicaid program'), 
or from any other third party payor.</DELETED>
        <DELETED>    ``(2) Application of 100 percent fmap.--The third 
        sentence of section 1905(b) of the Social Security Act (42 
        U.S.C. 1396d(b)) shall apply for purposes of reimbursement 
        under the medicaid program for health care services directly 
        billed under the program established under this 
        section.</DELETED>
<DELETED>    ``(b) Direct Reimbursement.--</DELETED>
        <DELETED>    ``(1) Use of funds.--Each hospital or clinic 
        participating in the program described in subsection (a) of 
        this section shall be reimbursed directly under the medicare 
        and medicaid programs for services furnished, without regard to 
        the provisions of section 1880(c) of the Social Security Act 
        (42 U.S.C. 1395qq(c)) and sections 402(a) and 813(b)(2)(A), but 
        all funds so reimbursed shall first be used by the hospital or 
        clinic for the purpose of making any improvements in the 
        hospital or clinic that may be necessary to achieve or maintain 
        compliance with the conditions and requirements applicable 
        generally to facilities of such type under the medicare or 
        medicaid programs. Any funds so reimbursed which are in excess 
        of the amount necessary to achieve or maintain such conditions 
        shall be used--</DELETED>
                <DELETED>    ``(A) solely for improving the health 
                resources deficiency level of the Indian tribe; 
                and</DELETED>
                <DELETED>    ``(B) in accordance with the regulations 
                of the Service applicable to funds provided by the 
                Service under any contract entered into under the 
                Indian Self-Determination Act (25 U.S.C. 450f et 
                seq.).</DELETED>
        <DELETED>    ``(2) Audits.--The amounts paid to the hospitals 
        and clinics participating in the program established under this 
        section shall be subject to all auditing requirements 
        applicable to programs administered directly by the Service and 
        to facilities participating in the medicare and medicaid 
        programs.</DELETED>
        <DELETED>    ``(3) Secretarial oversight.--</DELETED>
                <DELETED>    ``(A) Quarterly reports.--Subject to 
                subparagraph (B), the Secretary shall monitor the 
                performance of hospitals and clinics participating in 
                the program established under this section, and shall 
                require such hospitals and clinics to submit reports on 
                the program to the Secretary on a quarterly basis 
                during the first 2 years of participation in the 
                program and annually thereafter.</DELETED>
                <DELETED>    ``(B) Annual reports.--Any participant in 
                the demonstration program authorized under this section 
                as in effect on the day before the date of enactment of 
                the Alaska Native and American Indian Direct 
                Reimbursement Act of 1999 shall only be required to 
                submit annual reports under this paragraph.</DELETED>
        <DELETED>    ``(4) No payments from special funds.--
        Notwithstanding section 1880(c) of the Social Security Act (42 
        U.S.C. 1395qq(c)) or section 402(a), no payment may be made out 
        of the special funds described in such sections for the benefit 
        of any hospital or clinic during the period that the hospital 
        or clinic participates in the program established under this 
        section.</DELETED>
<DELETED>    ``(c) Requirements for Participation.--</DELETED>
        <DELETED>    ``(1) Application.--Except as provided in 
        paragraph (2)(B), in order to be eligible for participation in 
        the program established under this section, an Indian tribe, 
        tribal organization, or Alaska Native health organization shall 
        submit an application to the Secretary that establishes to the 
        satisfaction of the Secretary that--</DELETED>
                <DELETED>    ``(A) the Indian tribe, tribal 
                organization, or Alaska Native health organization 
                contracts or compacts for the operation of a facility 
                of the Service;</DELETED>
                <DELETED>    ``(B) the facility is eligible to 
                participate in the medicare or medicaid programs under 
                section 1880 or 1911 of the Social Security Act (42 
                U.S.C. 1395qq; 1396j);</DELETED>
                <DELETED>    ``(C) the facility meets the requirements 
                that apply to programs operated directly by the 
                Service; and</DELETED>
                <DELETED>    ``(D) the facility is accredited by an 
                accrediting body designated by the Secretary or has 
                submitted a plan, which has been approved by the 
                Secretary, for achieving such accreditation.</DELETED>
        <DELETED>    ``(2) Approval.--</DELETED>
                <DELETED>    ``(A) In general.--The Secretary shall 
                review and approve a qualified application not later 
                than 90 days after the date the application is 
                submitted to the Secretary unless the Secretary 
                determines that any of the criteria set forth in 
                paragraph (1) are not met.</DELETED>
                <DELETED>    ``(B) Grandfather of demonstration program 
                participants.--Any participant in the demonstration 
                program authorized under this section as in effect on 
                the day before the date of enactment of the Alaska 
Native and American Indian Direct Reimbursement Act of 1999 shall be 
deemed approved for participation in the program established under this 
section and shall not be required to submit an application in order to 
participate in the program.</DELETED>
                <DELETED>    ``(C) Duration.--An approval by the 
                Secretary of a qualified application under subparagraph 
                (A), or a deemed approval of a demonstration program 
                under subparagraph (B), shall continue in effect as 
                long as the approved applicant or the deemed approved 
                demonstration program meets the requirements of this 
                section.</DELETED>
<DELETED>    ``(d) Examination and Implementation of Changes.--
</DELETED>
        <DELETED>    ``(1) In general.--The Secretary, acting through 
        the Service, and with the assistance of the Administrator of 
        the Health Care Financing Administration, shall examine on an 
        ongoing basis and implement--</DELETED>
                <DELETED>    ``(A) any administrative changes that may 
                be necessary to facilitate direct billing and 
                reimbursement under the program established under this 
                section, including any agreements with States that may 
                be necessary to provide for direct billing under the 
                medicaid program; and</DELETED>
                <DELETED>    ``(B) any changes that may be necessary to 
                enable participants in the program established under 
                this section to provide to the Service medical records 
                information on patients served under the program that 
                is consistent with the medical records information 
                system of the Service.</DELETED>
        <DELETED>    ``(2) Accounting information.--The accounting 
        information that a participant in the program established under 
        this section shall be required to report shall be the same as 
        the information required to be reported by participants in the 
        demonstration program authorized under this section as in 
        effect on the day before the date of enactment of the Alaska 
        Native and American Indian Direct Reimbursement Act of 1999. 
        The Secretary may from time to time, after consultation with 
        the program participants, change the accounting information 
        submission requirements.</DELETED>
<DELETED>    ``(e) Withdrawal From Program.--A participant in the 
program established under this section may withdraw from participation 
in the same manner and under the same conditions that a tribe or tribal 
organization may retrocede a contracted program to the Secretary under 
authority of the Indian Self-Determination Act (25 U.S.C. 450 et seq.). 
All cost accounting and billing authority under the program established 
under this section shall be returned to the Secretary upon the 
Secretary's acceptance of the withdrawal of participation in this 
program.''.</DELETED>
<DELETED>    (b) Conforming Amendments.--</DELETED>
        <DELETED>    (1) Section 1880 of the Social Security Act (42 
        U.S.C. 1395qq) is amended by adding at the end the 
        following:</DELETED>
<DELETED>    ``(e) For provisions relating to the authority of certain 

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