[House Report 106-818]
[From the U.S. Government Publishing Office]
106th Congress Rept. 106-818
HOUSE OF REPRESENTATIVES
2d Session Part 1
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ALASKA NATIVE AND AMERICAN INDIAN DIRECT REIMBURSEMENT ACT OF 1999
_______
September 6, 2000.--Committed to the Committee of the Whole House on
the State of the Union and ordered to be printed
_______
Mr. Young of Alaska, from the Committee on Resources, submitted the
following
R E P O R T
[To accompany S. 406]
[Including cost estimate of the Congressional Budget Office]
The Committee on Resources, to whom was referred the bill (S.
406) 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, having considered the same,
report favorably thereon without amendment and recommend that
the bill do pass.
Purpose of the Bill
The purpose of S. 406 is 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
programs to other tribes and tribal organizations.
Background and Need for Legislation
The purpose of S. 406 is to make permanent a direct billing
demonstration program authorized by the Indian Health Care
Improvement Act Amendments of 1988, Public Law 100-713. The
bill makes the program permanent for the four demonstration
programs and expands the eligibility to other tribes and tribal
organizations which operate Indian Health Service (IHS)
hospitals and clinics. It provides that all funds received
through the program be used specifically to maintain
accreditation or, if that has been secured, to address the lack
of health resources available to that tribe. The bill
recognizes the success of the demonstration program, and that
the program enhances and reinforces the ideas contained in the
Indian Self-Determination and Assistance Act (Public Law 93-
638, 25 U.S.C. 450 et seq.) to strengthen the government-to-
government relationship between tribes and the federal
government.
Background
In exchange for the cession of millions of acres of land to
which Indian tribes held aboriginal title, the United States
entered into treaties with Indian nations. Many of the treaties
provided that health care services would be guaranteed to the
citizens of Indian country in perpetuity. The federal
obligation for the provision of health care services in Indian
country also arises out of the special trust relationship
between the United States and Indian tribes, as reflected in
Article I, Section 8, Clause 3 of the U.S. Constitution, which
has been given form and substance by numerous treaties, laws,
Supreme Court decisions, and Executive Orders.
In 1976, the Indian Health Care Improvement Act (IHCIA,
Public Law 94-437, 25 U.S.C. 1601 et seq.) became law. IHCIA
was the first comprehensive statute specifically addressing the
provision of health care in Indian country and the federal
administration of health care of Native Americans. In 1988,
amendments to IHCIA provided for the creation of a medicare and
medicaid direct billing demonstration program which is made
permanent by this legislation.
The IHS and Billing Practices
Prior to 1988, tribes who operated IHS hospitals and
clinics submitted their requests for reimbursement for medicare
and medicaid outlays or expenditures to the IHS. The submission
of that request began a complex, arduous process which did not
always result in payment.
Once a patient was seen by the IHS facility, a claim was
generated and sent to the IHS Area Office. The Area Office, in
turn, made a claim to the Fiscal Intermediary, the agent
responsible for processing medicare and medicaid claims
(oftentimes a state). Once the Fiscal Intermediary paid the IHS
Area Office, the funds were deposited in the federal reserve
and sent to the Department of the Treasury, where payment was
apportioned back to the IHS headquarters. The Area Office would
then request funds from IHS headquarters, and once the amount
an Area Office would receive was determined, the Area Office
would modify the tribe's contract to reflect the actual amount
received from IHS headquarters and which was to be paid to the
tribe. When the payment was finally received by the tribe
operating the IHS facility, it was always difficult, if not
impossible, for the tribe to determine which of the submitted
claims had been paid and which had been denied, as there was no
list provided which identified claim numbers to the tribe.
Often, according to tribal officials, if a payment register was
received, it would not be for months or years after the
original claim was made and no attempt could be made to
resubmit the claim. Officials reported periods as long as two
years between submission of a claim and reimbursement or denial
of the claim.
Tribal officials also claimed that for a period of time the
problems with a claim resulted from incorrect submissions made
by the IHS, whose computer system had malfunctioned. A medicare
audit later uncovered the errors, and tribes were made to repay
the overpayment claimed by the IHS system, along with
penalties, even though they had no control over the submission
to the Fiscal Intermediary, nor any way of determining that
they had in fact received an overpayment.\1\
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\1\ See Department of Health and Human Services, Report to Congress
on the tribal Demonstration Program on Direct Billing for Medicare,
Medicaid and Other Third Party Payors, Appendix D, December 15, 1998.
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History of the Demonstration Program
In 1988, the Indian Health Care Improvement Act was amended
to authorize a limited demonstration program for direct billing
by tribes. In the course of gathering information regarding the
IHCIA, several tribal leaders submitted comments regarding
their desire to streamline the process for billing medicare and
medicaid reimbursements. Specifically, Indian tribes and tribal
organizations who contracted the operation and administration
of IHS facilities stated that:
should they be allowed to retain all of the funds they
collect from Medicaid and Medicare reimbursements and
third party insurers, they could better control their
own cost accounting systems and accounts receivable,
and that they could thereby maximize and increase the
amounts collected from such sources. Tribes and tribal
organizations believe that the policy of self-
determination dictates this step toward a degree of
financial autonomy that will better equip them to one
day assume the full range of responsibilities that are
associated with the provision of health care. Evidence
submitted by tribal contractors in Alaska would
indicate that because of certain legal impediments that
exist to the collection of third party resources by the
Indian Health Service, tribal contractors can in fact
collect amounts from third party sources far in excess
of the amounts that Indian Health Service is able to
collect.
Senate Report 100-508, 100th Cong., 2nd Sess. 1988, 1988
U.S.C.C.A.N. 6183.
In 1996, Congress, based on evidence presented to it
regarding the success of the IHCIA demonstration program,
extended the program for two more years to allow time for the
Department of Health and Human Services to make its report to
Congress. The program was extended again in 1998, based upon a
favorable report made to Congress by the Department.
demonstration program results
Four facilities were chosen to participate in the
demonstration program: the Southeast Alaska Regional Health
Consortium (SEARHC), Sitka, Alaska; the Bristol Bay Area Health
Corporation, Dillingham, Alaska; the Choctaw Nation of
Oklahoma, Durant, Oklahoma; and the Mississippi Band of Choctaw
Indians, Philadelphia, Mississippi.
Under the terms of the demonstration program, the
participants were authorized to make claims directly to the
Fiscal Intermediary for reimbursement. To become a participant,
the tribe's facility had to meet IHS requirements for operation
of its own programs and the facility needed to be accredited by
the Joint Commission on Accreditation of Healthcare
Organizations.
All funds reimbursed were required to be used for specific
purposes. The first priority for the funds received was to make
improvements within the facility which would allow it to
maintain compliance with the conditions and requirements
applicable generally to all facilities under medicare and
medicaid programs (to continue to be accredited). If funds
remained after compliance was maintained, the excess was to be
used only to improve the health resources available to the
Indian tribe. All funds were to be expended in accordance with
IHS regulations applicable to funds provided by the IHS under a
contract entered into under the Indian Self-Determination Act
(25 U.S.C. 450 et seq.).
The Medicare and Medicaid Direct Billing Demonstration
Program was, by all accounts, a success. The Department of
Health and Human Services, in a report delivered to Congress in
December of 1998, stated that the ``demonstration project has
been a success as it has simplified, streamlined, and increased
collections.''
The Department reported that the direct billing process had
positive effects for the four participating tribes. First,
medicare and medicaid collections increased dramatically at all
four facilities. The increase in collections for both medicaid
and medicare combined ranged from 152% at the SEARHC facility
to 364% at the Bristol Bay facility. Second, the increased
collections were used by all four tribes to address compliance
issues at their facilities. During the term of the
demonstration project, all four facilities reported increases
in their status and ratings with the accrediting body and three
of the projects reported significant increases in their
standing. SEARHC reported receiving the highest score possible.
The SEARHC facility also received the highest ranking possible
for the years 1996 and 1997. Third, three of the four
participants also reported that they expended excess funds to
improve the health resources available to the tribe. Most of
these funds were used to improve facilities, to acquire
additional medical equipment, and to hire additional staff. The
Mississippi Band of Choctaw Indians reported that additional
funds were used to open three new clinics, geared toward
tuberculosis, diabetes and Women's Wellness. The Choctaw Nation
of Oklahoma reported program expansions at three locations, the
opening of a diabetes treatment center and the use of an
improved information system. The remaining participants
reported that the increased collections were used to hire new
staff and implement projects that both improved their
accreditation rating and improved the health resources offered
by the tribe. Finally, all projects reported a large decrease
in the amount of time between billing and collection. Each
tribe reported saving at least two months time, and one tribe
reported saving up to eight months time between billing and
collection. This was largely due to increased, direct contact
with the Fiscal Intermediary. The participants reported that
the direct contact with the Fiscal Intermediary allowed them to
``improve billings and collection practices, improve management
of accounts receivable, reduce the time between billing and
collection, and improve management planning on use of
collections.'' \2\
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\2\ See Department of Health and Human Services, Report to Congress
on the Tribal Demonstration Program on Direct Billing for Medicare,
Medicaid and Other Third Party Payors, page 9, December 15, 1998.
---------------------------------------------------------------------------
The Department of Health and Human Services recommended
that the demonstration program be made permanent and that the
program be open to an expanded number of participants. S. 406
creates a more efficient and effective means for the medicare
and medicaid reimbursement to tribes. But more importantly, it
is a recognition of the government to government relationship
that exists between the federal government and Indian tribes,
and furthers the policy of tribal self-determination by
allowing tribes to best determine the allocation and use of
funds received.
Committee Action
S. 406 was introduced on February 10, 1999, by Senator
Frank Murkowski (R-AK). The bill was passed by the Senate on
September 15, 1999, with amendments by unanimous consent. The
bill was referred primarily to the Committee on Resources, and
additionally to the Committee on Commerce and the Committee on
Ways and Means. On April 5, 2000, the Committee met to consider
the bill. No amendments were offered and the bill was then
ordered favorably reported by voice vote to the House of
Representatives.
Section by Section Analysis
section 1. short title
This section provides the short title of bill, the Alaska
Native and American Indian Direct Reimbursement Act of 1999.
section 2. findings
This section describes the history and of benefits of the
direct billing program.
section 3. direct billing of medicare, medicaid, and other third party
payors
Subsection (a) amends Section 405 of IHCIA (25 U.S.C. 1645)
to provide for the permanent authorization and establishment of
the direct billing program. Specifically, the amendments to
Section 405 of IHCIA are as follows:
Subsection (a)(1) authorizes tribes to directly bill for
payment to be made under the medicare program (Title XVIII of
the Social Security Act (42 U.S.C. 1395 et seq.)), state plans
for medical assistance approved under Title XIX of the Social
Security Act, and third party payors.
Subsection (a)(2) provides for direct billing from the
medicaid program (section 1905(b) of the Social Security Act,
42 U.S.C. 1396(b)).
Subsection (b)(1) specifies that the funds reimbursed will
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 to facilities of such type under
the medicare or medicaid programs.
Subsection (b)(2) states that all tribal hospitals and
clinics participating in the program shall be subject to all
auditing requirements applicable to programs administered
directly by the IHS.
Subsection (b)(3) provides for Secretarial (of the
Department of Health and Human Services) oversight of the
program by requiring the submission of annual reports by
participants of the program.
Subsection (b)(4) ensures that no payments will be made out
of the special funds described in Section 1880(c) of the Social
Security Act (42 U.S.C. 1395qq(c)) or section 402(a) of IHCIA.
Subsection (c)(1) establishes the eligibility requirements
for participation in the program.
Subsection (c)(2) sets forth the required contents of the
tribal application for participation in the program; the
timeline for approval of the submitted applications; allows for
the continued, uninterrupted participation of the demonstration
program participants; and states the duration of the approved
application.
Subsection (d)(1) gives the authority to the Secretary of
the Department of Health and Human Services for the
implementation of any administrative changes that may be
necessary to facilitate direct billing and reimbursement.
Subsection (d)(2) sets out the reporting requirements for
accounting information that a participant will have to submit
to the Secretary, and provides for periodic changes in the
required information.
Subsection (e) allows for a participant to withdraw from
the program in the same manner that a tribe retrocedes a
contracted program to the Secretary of Health and Human
Services under authority of the Indian Self-Determination Act
(25 U.S.C. 450 et seq.)
The remaining subsections provide for conforming amendments
and an effective date of October 1, 2000.
Committee Oversight Findings and Recommendations
Regarding clause 2(b)(1) of rule X and clause 3(c)(1) of
rule XIII of the Rules of the House of Representatives, the
Committee on Resources' oversight findings and recommendations
are reflected in the body of this report.
Constitutional Authority Statement
Article I, section 8 of the Constitution of the United
States grants Congress the authority to enact this bill.
Compliance With House Rule XIII
1. Cost of Legislation. Clause 3(d)(2) of rule XIII of the
Rules of the House of Representatives requires an estimate and
a comparison by the Committee of the costs which would be
incurred in carrying out this bill. However, clause 3(d)(3)(B)
of that rule provides that this requirement does not apply when
the Committee has included in its report a timely submitted
cost estimate of the bill prepared by the Director of the
Congressional Budget Office under section 402 of the
Congressional Budget Act of 1974.
2. Congressional Budget Act. As required by clause 3(c)(2)
of rule XIII of the Rules of the House of Representatives and
section 308(a) of the Congressional Budget Act of 1974, this
bill does not contain any new budget authority, credit
authority, or an increase or decrease in revenue or tax
expenditures. According to the Congressional Budget Office,
enactment of S. 406 would increase federal outlays by $8-9
million in each of fiscal years 2001 through 2005.
3. Government Reform Oversight Findings. Under clause
3(c)(4) of rule XIII of the Rules of the House of
Representatives, the Committee has received no report of
oversight findings and recommendations from the Committee on
Government Reform on this bill.
4. Congressional Budget Office Cost Estimate. Under clause
3(c)(3) of rule XIII of the Rules of the House of
Representatives and section 403 of the Congressional Budget Act
of 1974, the Committee has received the following cost estimate
for this bill from the Director of the Congressional Budget
Office:
U.S. Congress,
Congressional Budget Office,
Washington, DC, May 1, 2000.
Hon. Don Young,
Chairman, Committee on Resources,
House of Representatives, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for S. 406, the Alaska
Native and American Indian Direct Reimbursement Act of 1999.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contacts for federal
costs and intergovernmental mandates are Eric Rollins and Leo
Lex, respectively.
Sincerely,
Barry B. Anderson
(For Dan L. Crippen, Director).
Enclosure.
S. 406--Alaska Native and American Indian Direct Reimbursement Act of
1999
Summary: S. 406 would extend indefinitely an Indian Health
Service (IHS) demonstration project that allows four tribally
operated IHS facilities to bill the Medicare and Medicaid
programs directly, rather than submitting their claims through
the IHS. The act also would allow all other tribally operated
IHS facilities to bill Medicare and Medicaid directly. CBO
estimates that S. 406 would raise federal outlays by $8 million
to $9 million in each of fiscal years 2001 through 2005.
(Federal Medicare outlays would be higher by about $2 million a
year, and federal Medicaid outlays would be higher by about $6
million a year.) Because the act would affect direct spending,
pay-as-you-go procedures would apply.
S. 406 contains no private-sector or intergovernmental
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
Participation in the direct billing program would improve the
cash-flow of health facilities operated by tribal governments
and increase their total Medicaid funding.
Estimated cost to the Federal Government: The estimated
budgetary impact of S. 406 is shown in the following table. The
costs of this legislation fall within budget functions 550
(health) and 570 (Medicare).
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Outlays, by fiscal year, in millions of
dollars--
-----------------------------------------------
2000 2001 2002 2003 2004 2005
----------------------------------------------------------------------------------------------------------------
CHANGES IN DIRECT SPENDING
Medicare........................................................ 0 3 2 2 2 2
Medicaid........................................................ 0 6 6 5 5 6
-----------------------------------------------
Total..................................................... 0 9 8 8 8 8
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Note. Components may not sum to totals because of rounding.
Basis of Estimate: Under current law, four tribally
operated Indian Health Service demonstration sites are
authorized to bill the Medicare and Medicaid programs directly
rather than submitting their claims through the IHS. The
demonstration authority expires on September 30, 2000. S. 406
would allow all tribally operated IHS facilities to bill
Medicare and Medicaid directly.
According to IHS, seven hospitals are tribally operated and
would likely choose to bill Medicare and Medicaid directly. In
1999, Medicare and Medicaid collections totaled $56 million in
these facilities. In addition, more than 150 health stations,
health centers, and clinics would be eligible to bill directly
under the legislation. CBO assumes that all of the hospitals
would choose to bill directly over the next several years but
that only a few of the largest of the other facilities would
develop the infrastructure necessary to adopt direct billing.
CBO further assumes that a few additional hospitals would
become tribally operated and begin to bill directly.
Based on information from the IHS on the experiences in the
demonstration sites, CBO expects that direct billing would
increase Medicare and Medicaid payments for two reasons. First,
the demonstration sites report a reduction in the amount of
time between filing reimbursement claims and receiving payment.
CBO therefore assumes that in the first year a facility
participated in direct billing, it would receive one to two
extra months worth of Medicare and Medicaid payments. The
legislation would also accelerate federal spending for the four
existing demonstration sites because under current law they are
required to return to billing Medicare and Medicaid through IHS
and will therefore experience a one- to two-month slow-down in
Medicare and Medicaid collections. Of the $41 million in
estimated Medicare and Medicaid costs over the 2001-2005
period, $10 million is attributable to the one-time
acceleration of payments.
Second, demonstration sites also reported increased
Medicare and Medicaid payments under direct billing because of
improved claims processing. The sites reported that they were
better able to track their claims and correct errors under
direct billing than when they filed their claims through the
IHS. Medicare and Medicaid payments have grown dramatically in
both demonstration sites and nondemonstration IHS facilities in
the 11 years since the demonstration was authorized. Much of
the growth stems from higher Medicare and Medicaid
reimbursement rates for IHS facilities, efforts by IHS to
improve its Medicare and Medicaid collections, and general
growth in medical costs and enrollment, rather than from direct
billing. Nonetheless, based on the experience in the
demonstration sites, CBO estimates that the improved claims
processing procedures that would result from direct billing
would increase Medicare and Medicaid payments by about 10
percent for the facilities that choose to undertake it.
In addition, direct billing may slightly reduce IHS
administrative costs, which are subject to annual
appropriation.
Pay-As-You-Go Considerations: The Balanced Budget and
Emergency Deficit Control act sets up pay-as-you-go procedures
for legislation affecting direct spending or receipts. The net
changes in outlays that are subject to pay-as-you-go procedures
are shown in the following table. (S. 406 would not affect
receipts.) For the purposes of enforcing pay-as-you-go
procedures, only the effects in the current year, the budget
year, and the succeeding four years are counted.
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
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2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
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Changes in outlays................. 0 9 8 8 8 8 9 9 10 10 11
Changes in receipts................ Not applicable
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Estimated impact on State, local, and tribal governments:
S. 406 contains no intergovernmental mandates as defined in
UMRA. by allowing all tribally operated IHS facilities to
directly bill the Department of Health and Human Services for
Medicare and Medicaid services, the act would shorten the
period of time for receiving reimbursements and improve
processing procedures. CBO estimates that those facilities
would receive a total of between $5 million and $7 million
annually in additional Medicaid reimbursements. Since the
federal medical assistance percentage is 100 percent for tribal
health facilities, S. 406 would increase total funding and
improve the cash-flow position of facilities that chose to
participate in the direct billing program.
Estimated impact on the private sector: S. 406 contains no
private-sector mandates as defined in UMRA.
Previous CBO estimate: On August 27, 1999, CBO estimated
that S. 406, as ordered reported by the Senate Committee on
Indian Affairs on August 4, 1999, would increase direct
spending by $37 million over the 2000-2004 period. The language
in the Senate version of S. 406 is substantively the same as
that in the version that was ordered reported by the House
Committee on Resources. CBO has updated its earlier estimate to
include more recent data on Medicare and Medicaid collections
by IHS facilities (which were lower than expected) and to show
the legislation's effects in 2005.
Estimate prepared by: Federal costs: Eric Rollins; impact
on State, local, and tribal governments: Leo Lex; impact on the
private sector: Stuart Hagen.
Estimate approved by: Peter H. Fontaine, Deputy Assistant
Director for Budget Analysis.
Compliance With Public Law 104-4
This bill contains no unfunded mandates.
Preemption of State, Local or Tribal Law
This bill is not intended to preempt any State, local or
tribal law.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, existing law in which no change is
proposed is shown in roman):
SECTION 405 OF THE INDIAN HEALTH CARE IMPROVEMENT ACT
DEMONSTRATION PROGRAM FOR DIRECT BILLING OF MEDICARE, MEDICAID, AND
OTHER THIRD PARTY PAYORS
Sec. 405. [(a) The Secretary shall establish a demonstration
program under which Indian tribes, tribal organizations, and
Alaska Native health organizations, which are contracting the
entire operation of an entire hospital or clinic of the Service
under the authority of the Indian Self-Determination Act, shall
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
(medicare), under a State plan for medical assistance approved
under title XIX of the Social Security Act (medicaid), or from
any other third-party payor. The last sentence of section
1905(b) of the Social Security Act shall apply for purposes of
the demonstration program.
[(b)(1) Each hospital or clinic participating in the
demonstration program described in subsection (a) 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 and sections
sections 402(a) and 813(b)(2)(A) of this Act, 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 program.
Any funds so reimbursed which are in excess of the amount
necessary to achieve or maintain such conditions or
requirements shall be used--
[(A) solely for improving the health resources
deficiency level of the Indian tribe, and
[(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.
[(2) The amounts paid to the hospitals and clinics
participating in the demonstration program described in
subsection (a) 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.
[(3) The Secretary shall monitor the performance of hospitals
and clinics participating in the demonstration program
described in subsection (a), and shall require such hospitals
and clinics to submit reports on the program to the Secretary
on a quarterly basis (or more frequently if the Secretary deems
it to be necessary).
[(4) Notwithstanding section 1880(c) of the Social Security
Act or section 402(a) of this Act, no payment may be made out
of the special fund described in section 1880(c) of the Social
Security Act, or section 402(a) of this Act, for the benefit of
any hospital or clinic participating in the demonstration
program described in subsection (a) during the period of such
participation.
[(c)(1) In order to be considered for participation in the
demonstration program described in subsection (a), a hospital
or clinic must submit an application to the Secretary which
establishes to the satisfaction of the Secretary that--
[(A) the Indian tribe, tribal organization, or Alaska
Native health organization contracts the entire
operation of the Service facility;
[(B) the facility is eligible to participate in the
medicare and medicaid programs under sections 1880 and
1911 of the Social Security Act;
[(C) the facility meets any requirements which apply
to programs operated directly by the Service; and
[(D) the facility is accredited by the Joint
Commission on Accreditation of Hospitals, or has
submitted a plan, which has been approved by the
Secretary, for achieving such accreditation prior to
October 1, 1990.
[(2) From among the qualified applicants, the Secretary
shall, prior to October 1, 1989, select no more than 4
facilities to participate in the demonstration program
described in subsection (a). The demonstration program
described in subsection (a) shall begin by no later than
October 1, 1991, and end on September 30, 1996.
[(d)(1) Upon the enactment of the Indian Health Care
Amendments of 1988, the Secretary, acting through the Service,
shall commence an examination of--
[(A) any administrative changes which may be
necessary to allow direct billing and reimbursement
under the demonstration program described in subsection
(a), including any agreements with States which may be
necessary to provide for such direct billing under the
medicaid program; and
[(B) any changes which may be necessary to enable
participants in such demonstration program to provide
to the Service medical records information on patients
served under such demonstration program which is
consistent with the medical records information system
of the Service.
[(2) Prior to the commencement of the demonstration program
described in subsection (a), the Secretary shall implement all
changes required as a result of the examinations conducted
under paragraph (1).
[(3) Prior to October 1, 1990, the Secretary shall determine
any accounting information which a participant in the
demonstration program described in subsection (a) would be
required to report.
[(f) The Secretary shall provide for the retrocession of any
contract entered into between a participant in the
demonstration program described in subsection (a) and the
Service under the authority of the Indian Self-Determination
Act. All cost accounting and billing authority shall be
retroceded to the Secretary upon the Secretary's acceptance of
a retroceded contract.]
(a) Establishment of Direct Billing Program.--
(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.
(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.
(b) Direct Reimbursement.--
(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--
(A) solely for improving the health resources
deficiency level of the Indian tribe; and
(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.).
(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.
(3) Secretarial oversight.--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 an
annual basis.
(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.
(c) Requirements for Participation.--
(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--
(A) the Indian tribe, tribal organization, or
Alaska Native health organization contracts or
compacts for the operation of a facility of the
Service;
(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);
(C) the facility meets the requirements that
apply to programs operated directly by the
Service; and
(D) the facility--
(i) is accredited by an accrediting
body as eligible for reimbursement
under the medicare or medicaid
programs; or
(ii) has submitted a plan, which has
been approved by the Secretary, for
achieving such accreditation.
(2) Approval.--
(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.
(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.
(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.
(d) Examination and Implementation of Changes.--
(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--
(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
(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.
(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.
(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.
----------
SOCIAL SECURITY ACT
* * * * * * *
TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED
* * * * * * *
Part D--Miscellaneous Provisions
* * * * * * *
indian health service facilities
Sec. 1880. (a) * * *
* * * * * * *
(e) 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).
* * * * * * *
TITLE XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS
* * * * * * *
INDIAN HEALTH SERVICE FACILITIES
Sec. 1911. (a) * * *
* * * * * * *
(d) 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).
* * * * * * *
A P P E N D I X
----------
House of Representatives,
Committee on Resources,
Washington, DC, June 13, 2000.
Hon. Tom Bliley,
Chairman, Committee on Commerce,
Rayburn HOB, Washington, DC.
Dear Mr. Chairman: On April 5, 2000, the Committee on
Resources ordered reported without amendment S. 406, the Alaska
Native and American Indian Direct Reimbursement Act of 1999.
The Senate passed the bill by unanimous consent on September
15, 1999. The purpose of the bill is to make permanent a very
successful demonstration program under the Indian Health Care
Improvement Act Amendments (Public Law 100-713) that allows
tribes to directly bill for Medicare and Medicaid
reimbursements. S. 406 was primarily referred to the Committee
on Resources and additionally to the Committee on Commerce and
the Committee on Ways and Means.
Because of the limited numbers of days remaining in the
106th Congress, I seek your help in allowing S. 406 to be
scheduled for consideration by the House of Representatives
without further action by the Committee on Commerce. I would
propose to pass the Senate bill without amendment and forward
it to the President for signature.
Of course, by allowing this to occur, the Committee on
Commerce does not waive its jurisdiction over S. 406 or any
other similar matter, and this action should not be seen as
precedent for any other Senate bills which affect the Committee
on Commerce's jurisdiction. I can place this letter and your
response in the Committee on Resources' bill report or to
insert our exchange of letters in the Congressional Record
during consideration of the bill on the Floor to document this
agreement.
I appreciate your continued cooperation and that of your
staff in moving this important Native American bill, as well as
several others this session of Congress.
Sincerely,
Don Young, Chairman.
----------
House of Representatives,
Committee on Commerce,
Washington, DC, June 13, 2000.
Hon. Don Young,
Chairman, Committee on Resources, Longworth House Office Building,
Washington, DC.
Dear Don: I am writing with regard to S. 406, the Alaska
Native and American Indian Direct Reimbursement Act of 1999. As
you know, Rule X of the Rules of the House of Representatives
grants the Committee on Commerce jurisdiction over public
health and quarantine. Accordingly, legislation addressing the
interaction of the Indian Health Service with the Medicare and
Medicaid programs fall within the Committee's jurisdiction.
Section 3 of S. 406, as ordered reported by the Committee
on Resources, makes permanent a demonstration project
permitting Indian Health Service (IHS) facilities to bill the
Medicare and Medicaid programs directly, rather than requiring
all such billing to be routed through IHS.
Because of the importance of this legislation, I recognize
your desire to bring it before the House in an expeditious
manner, and I will not exercise the Committee's right to
exercise its referral. By agreeing to waive its consideration
of the bill, however, the Committee on Commerce does not waive
its jurisdiction over S. 406. In addition, the Commerce
Committee reserves its authority to seek conferees on any
provisions of the bill that are within its jurisdiction during
any House-Senate conference that may be convened on this
legislation, should it be amended. I ask for your commitment to
support any request by the Commerce Committee for conferees on
S. 406 or similar legislation.
I request that you include this letter and your response in
your committee report on the bill and as part of the Record
during consideration of the legislation on the House floor.
Thank you for your attention to these matters.
Sincerely,
Tom Bliley, Chairman.
----------
House of Representatives,
Committee on Resources,
Washington, DC, July 28, 2000.
Hon. Bill Archer,
Chairman, Committee on Ways and Means,
Longworth HOB, Washington, DC.
Dear Mr. Chairman: On April 5, 2000, the Committee on
Resources ordered reported without amendment S. 406, the Alaska
native and American Indian Direct Reimbursement Act of 1999.
The Senate passed the bill by unanimous consent on September
15, 1999. The purpose of the bill is to make permanent a very
successful demonstration program under the Indian Health Care
Improvement Act Amendments that allows tribes to directly bill
for Medicare and Medicaid reimbursements. S. 406 was primarily
referred to the Committee on Resources and additionally to the
Committees on Commerce and Ways and Means.
Because of the limited numbers of days remaining in the
106th Congress, I seek your help in allowing S. 406 to be
scheduled for consideration by the House of Representatives
without further action by the Committee on Ways and Means. As
you outlined in your letter, I propose to pass the Senate bill
without amendment under suspension of the bills and forward it
to the President for signature. Chairman Bill Bliley of the
Committee on Commerce has agreed to this procedure.
Of course, by allowing this to occur, the Committee on Ways
and Means does not waive its jurisdiction over S. 406 or any
other similar matter, and this action should not be seen as
precedent for any other Senate bills which affect your
Committee's jurisdiction. I can place this letter and your
response in the Committee on Resources' bill report to document
this agreement.
I appreciate your continued cooperation and that of your
staff in moving this important Native American bill.
Sincerely,
Don Young, Chairman.
----------
House of Representatives,
Committee on Ways and Means,
Washington, DC, July 28, 2000.
Hon. Don Young,
Chairman, Committee on Resources, Longworth House Office Building,
Washington, DC.
Dear Mr. Chairman: I am writing in regard to S. 406, the
Alaska Native and American Indian Direct Reimbursement Act of
1999, as ordered reported by the Committee on Resources.
The bill would make permanent a demonstration project
permitting Indian Health Service (IHS) facilities to bill the
Medicare program directly, rather than requiring all billing to
be routed through the IHS. As you know, legislation addressing
the interaction of the Indian Health Service with the Medicare
program would fall within the jurisdiction of the Committee on
Ways and Means.
Normally, the committee would meet to consider such
legislation. However, in order to expedite consideration of S.
406, I will not object to this legislation, and, for this
reason, it will not be necessary for the committee on Ways and
means to meet to consider the bill.
However, this is being done with the understanding that you
will bring the bill to the floor under suspension of the rules
for final action prior to transmission of the bill to the
President, and that you have agreed to accept no additional
changes on these or any other matters of concern to this
Committee during further consideration of this legislation.
This action is also being done with the understanding that it
will not prejudice the jurisdictional prerogatives of the
Committee on Ways and Means on these provisions or any other
similar legislation and will not be considered as precedent for
consideration of matters of jurisdictional interest to my
Committee in the future.
Finally, I would ask that you include a copy of our
exchange of letters on this matter in your Committee Report on
the legislation. Thank you for your assistance and cooperation
in this matter. With warm personal regards,
Sincerely,
Bill Archer, Chairman.