[Senate Report 114-376]
[From the U.S. Government Publishing Office]
Calendar No. 671
114th Congress } { Report
SENATE
2d Session } { 114-376
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A BILL TO AMEND THE INDIAN HEALTH CARE IMPROVEMENT ACT TO ALLOW THE
INDIAN HEALTH SERVICE TO COVER THE COST OF A COPAYMENT OF AN INDIAN OR
ALASKA NATIVE VETERAN RECEIVING MEDICAL CARE OR SERVICES FROM THE
DEPARTMENT OF VETERANS AFFAIRS, AND FOR OTHER PURPOSES
_______
November 16, 2016.--Ordered to be printed
_______
Mr. Barrasso, from the Committee on Indian Affairs,
submitted the following
R E P O R T
[To accompany S. 2417]
The Committee on Indian Affairs, to which was referred the
bill (S. 2417) to amend the Indian Health Care Improvement Act
to allow the Indian Health Service to cover the cost of a
copayment of an Indian or Alaska Native veteran receiving
medical care or services from the Department of Veterans
Affairs, and for other purposes, having considered the same,
reports favorably thereon without amendment and recommends that
the bill do pass.
Purpose
The purpose of this bill is to amend section 222(a) of the
Indian Health Care Improvement Act (IHCIA). It would authorize
the Indian Health Service (IHS) to cover the cost of copayments
for American Indian or Alaska Native (collectively referred to
as ``Indian'') veterans receiving medical care or services from
the Department of Veterans Affairs (VA) upon an authorized
referral from the IHS. The bill would require an MOU between
the IHS and VA that allows the IHS to use Purchase Referred
Care Program funds (PRC) to cover the cost of VA copayments
assessed upon Indian veterans who are treated, through a IHS
referral, at a VA facility. Under the PRC program, the IHS may
reimburse private non-IHS healthcare providers for treating
Indian patients using PRC funds (PRC funds).
Need for Legislation
This bill is needed to amend current federal law to clarify
that the IHS is authorized to use PRC funding to cover the
copayment cost of an Indian veteran being treated at a VA
healthcare facility with an approved referral from an IHS
provider.
Background
Originally enacted in 1976,\1\ the IHCIA was permanently
authorized as part of the Patient Protection and Affordable
Care Act.\2\ The IHCIA governs many programs for the provision
of health care services and programs for Indians.
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\1\Pub. L. No. 94-437, Sept. 30, 1976, 90 Stat. 1400 (codified at
25 U.S.C. Sec. Sec. 1601-1683).
\2\Pub. L. No. 111-148, Mar. 23, 2010, 124 Stat. 119 (codified at
42 U.S.C. Sec. 18001 et seq.).
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The IHS is the primary agency responsible for providing
federal health care services to Indians either directly or
through contracts or compacts negotiated with Indian tribes.
When specific healthcare services are not available through IHS
or tribal providers, the IHS may, through the PRC program,
provide referrals to Indian patients so that they can be
treated by non-IHS healthcare providers.
The IHCIA allows for the IHS and VA to enter into
agreements for the reimbursement of healthcare services.\3\
Under federal law, IHS can be reimbursed by the VA for
providing services for eligible beneficiaries.\4\ However,
according to IHS, under federal law\5\ there is no authority
for a provider, including the VA, to impose financial liability
on an IHS patient pursuant to an authorized PRC referral.\6\
The prohibition against liability of payment for health
services to Indian patients would include a VA copay assessed
for Indian veterans that receive care at VA facilities pursuant
to an IHS referral. As a result, VA is not able to be
reimbursed from PRC funds for the copay assessed upon an Indian
veteran who, pursuant to the PRC referral, has received
services at a VA facility.
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\3\25 U.S.C. Sec. 1645(a)(1)
\4\25 U.S.C. Sec. 1645(c)
\5\See 25 U.S.C. Sec. 1623(b) and 25 U.S.C. Sec. 1647(c)) as cited
in official congressional correspondence with IHS.
\6\25 U.S.C. 1621u
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Legislative History
On December 15, 2015, Senator Thune introduced S. 2417 with
Senator Rounds as a cosponsor. On May 11, 2016, the Committee
held a legislative hearing on the bill in which Roger Trudell,
Chairman of the Santee Sioux Tribe and Indian veteran,
testified in favor of the bill. The administration did not
provide testimony on the bill at the hearing. On June 6, 2016
the Committee met in a duly called business meeting to consider
the bill. The Committee then ordered the bill to be reported
favorably without amendment to the Senate.
Section-by-Section Analysis of Bill as Ordered Reported
Section 1--Short title
Section 1 states that the Act may be cited as the ``Tribal
Veterans Health Care Enhancement Act''.
Section 2--Copayments for Indian veterans receiving certain medical
services
Section 2(a) amends Section 222(a) of the Indian Health
Care Improvement Act (25 U.S.C. 1621u(a)) by authorizing the
IHS to pay for copayments assessed to eligible Indian veterans
by the Department of Veterans Affairs.
Section 2(b) provides a definition of eligible Indian
veterans as a veteran that (1) receives an authorized referral
from IHS and (2) has their healthcare services administered at
a VA facility.
Section 2(b) amends section 2901(b) of the Patient
Protection and Affordable Care Act (25 U.S.C. 1623(b)) to
provide authorization for the VA to accept copayments from the
IHS.
Section 2(c) requires the IHS and VA to enter into a
Memorandum of Understanding (MOU) to provide for the payment of
copayments.
Section 2(c) provides that the required MOU can be waived
if the IHS and VA certify to Congress that doing so would
decrease the quality of care or impede access to medical care
for the patients that they serve.
Section 2(c) requires the Director of the IHS and Secretary
of the VA to submit, within 45 days of enactment, a report to
the Committee on Indian Affairs of the Senate, Committee on
Veterans Affairs of the Senate, the Committee on Veterans
Affairs of the House of Representatives, and Committee on
Natural Resources of the House of Representatives a report that
includes:
the number, by state, of eligible Indian
veterans utilizing VA medical facilities;
the number of referrals, by state, received
annually from the Indian Health Service from 2010 to
2015; and
an update on efforts at the VA and IHS to
streamline care for eligible Indian veterans who
receive care at both the VA and the IHS including
changes required under the Indian Health Care
Improvement Act and any barriers to achieve
efficiencies.
Cost and Budgetary Considerations
The following cost estimate for S. 2417, as provided by the
Congressional Budget Office, dated September 12, 2016.
September 12, 2016.
Hon. John Barrasso,
Chairman, Committee on Indian Affairs,
U.S. Senate, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for S. 2417, the Tribal
Veterans Health Care Enhancement Act.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Robert
Stewart.
Sincerely,
Keith Hall.
Enclosure.
S. 2417--Tribal Veterans Health Care Enhancement Act
S. 2417 would allow the Indian Health Service (IHS) to
cover the cost of any copayment assessed by the Department of
Veterans Affairs (VA) to an eligible Indian veteran who is
referred to the VA for treatment. Based on an analysis of
information from an IHS report regarding Indian veterans, CBO
estimates that there would be, on average, about 5,000 Indian
veterans treated annually at IHS facilities over the 2017 to
2021 period. Some of these Indian veterans would be referred to
VA health facilities for more complex care that could not be
provided at IHS facilities. A small percentage of those
referred veterans would make copayments to the VA based on
their VA priority group. Using information provided by the VA
regarding the collection of copayments from veterans, CBO
estimates that S. 2417 would cost less than $500,000 over the
2017 to 2021 period; such spending would be subject to the
availability of appropriated funds. Enacting S. 2417 would not
affect direct spending or revenues; therefore, pay-as-you-go
procedures do not apply.
CBO estimates that enacting S. 2417 would not increase net
direct spending or on-budget deficits in any of the four
consecutive 10-year periods beginning in 2027.
S. 2417 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act and
would not affect the budgets of state, local, or tribal
governments. American Indian and Alaska Native military
veterans would benefit from provisions in the bill that
authorize copayments for medical treatment received from the
VA.
The CBO staff contact for this estimate is Robert Stewart.
The estimate was approved by Holly Harvey, Deputy Assistant
Director for Budget Analysis.
Executive Communications
The Committee has received no communications from the
Executive Branch regarding S. 2417.
Regulatory and Paperwork Impact Statement
Paragraph 11(b) of rule XXVI of the Standing Rules of the
Senate requires each report accompanying a bill to evaluate the
regulatory and paperwork impact that would be incurred in
carrying out the bill. The Committee believes that S. 2417 will
have a minimal impact on regulatory or paperwork requirements.
Changes in Existing Law (Cordon Rule)
In accordance with subsection 12 of rule XXVI of the
Standing Rules of the Senate, changes in existing law made by
S. 2417, as ordered reported, are shown as follows (existing
law proposed to be omitted is enclosed in black brackets, new
matter is printed in italic):
25 U.S.C. Sec. 1621 (Indian Healthcare Improvement Act)
SEC. 222. LIABILITY FOR PAYMENT.
(a) No Patient Liability.--
[A patient] (1) In general.--Subject to paragraph
(2), a patient who receives contract health care
services that are authorized by the Service shall not
be liable for the payment of any charges or costs
associated with the provision of such services.
(2) Veterans affairs copayments.--The Service may
pay, in accordance with section 405(d), the cost of a
copayment assessed by the Department of Veterans
Affairs to an eligible Indian veteran (as defined in
section 405(d)(1)).
25 U.S.C. Sec. 1645 (Indian Healthcare Improvement Act)
SEC. 405. SHARING ARRANGEMENTS WITH FEDERAL AGENCIES.
(a) Authority.--
(1) In general.--The Secretary may enter into (or
expand) arrangements for the sharing of medical
facilities and services between the Service, Indian
tribes, and tribal organizations and the Department of
Veterans Affairs and the Department of Defense.
(2) Consultation by secretary required.--The
Secretary may not finalize any arrangement between the
Service and a Department described in paragraph (1)
without first consulting with the Indian tribes which
will be significantly affected by the arrangement.
(b) Limitations.--The Secretary shall not take any action
under this section or under subchapter IV of chapter 81 of
title 38 which would impair--
(1) the priority access of any Indian to health care
services provided through the Service and the
eligibility of any Indian to receive health services
through the Service;
(2) the quality of health care services provided to
any Indian through the Service;
(3) the priority access of any veteran to health care
services provided by the Department of Veterans
Affairs;
(4) the quality of health care services provided by
the Department of Veterans Affairs or the Department of
Defense; or
(5) the eligibility of any Indian who is a veteran to
receive health services through the Department of
Veterans Affairs.
(c) Reimbursement.--The Service, Indian tribe, or tribal
organization shall be reimbursed by the Department of Veterans
Affairs or the Department of Defense (as the case may be) where
services are provided through the Service, an Indian tribe, or
a tribal organization to beneficiaries eligible for services
from either such Department, notwithstanding any other
provision of law.
(d) Payments for Eligible Indian Veterans Receiving Medical
Services at VA Facilities.--
(1) Definition of eligible indian veteran.--In this
subsection, the term ``eligible Indian veteran'' means
an Indian or Alaska Native veteran who receives any
medical care or service that is--
(A) authorized on referral by the Service;
and
(B) administered at a facility of the
Department of Veterans Affairs.
(2) Payment by service.--Notwithstanding any other
provision of law, the Service may cover the cost of any
copayment assessed by the Department of Veterans
Affairs to an eligible Indian veteran receiving
services authorized under the Purchased/Referred Care
program.
(3) Authorization to accept funds.--Notwithstanding
section 407(c) of this Act, section 2901(b) of the
Patient Protection and Affordable Care Act (25 U.S.C.
1623(b)), or any other provision of law, the Secretary
of Veterans Affairs may accept a payment from the
Service under paragraph (2).
[(d)](e) Construction.--Nothing in this section may be
construed as creating any right of a non-Indian veteran to
obtain health services from the Service.
[all]