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                                                      Calendar No. 149
115th Congress     }                                    {       Report
 1st Session       }                                    {      115-112




                 June 15, 2017.--Ordered to be printed


           Mr. Hoeven, from the Committee on Indian Affairs, 
                        submitted the following

                              R E P O R T

                         [To accompany S. 304]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Indian Affairs, to which was referred the 
bill (S. 304) 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.


    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 dollars (PRC dollars).

                          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 


    Originally enacted in 1976\1\ the IHCIA was permanently 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.
    \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.).
    The IHS is the primary agency responsible for providing 
federal health care services to Indians either directly or 
through contracts 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 current federal law\5\ there is no authority for a 
provider, including VA, to impose financial liability on a 
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 through 
PRC funds for the copay assessed Indian veteran who has 
received services at a VA facility.
    \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.

                          LEGISLATIVE HISTORY

    On February 3, 2017, Senator Thune introduced S. 304 with 
Senator Rounds as a cosponsor. A previous version of this bill, 
S. 304 was introduced in the 114th Congress. At the legislative 
hearing held on May 11, 2016, on the previous version of this 
bill, 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 March 28, 2017 at a duly called business meeting, 
the Committee voted to approve S. 304, without amendment. The 
Committee then ordered the bill to be reported favorably 
without amendment to the Senate.


Section 1. Short title

    Section 1 titles the bill as the ``Tribal Veterans Health 
Care Enhancement Act.''

Section 2. Liability for payment

    Section 2 amends the IHCIA by adding a section that allows 
for the IHS to reimburse the VA for the cost of a co-pay 
assessed by the VA to an eligible Indian veteran for medical 
care at a VA facility.

Section 3. Copayments for tribal veterans receiving certain medical 

    Section 3(a) amends the IHCIA to provide that copayment 
reimbursement by the IHS to the VA can only be for:
           Indian veterans;
           that receive an authorized referral from the 
           for medical services provided by the VA at a 
        VA facility.
    Section 3(b) provides that the VA and the IHS shall enter 
into a memorandum of understanding (110U) that provides for 
process of payment and reimbursement of VA assessed co-payments 
between the IHS and the VA.
    Section 3(c) provides that the IHS is authorized to provide 
for the payment of the VA assessed co-payments.
    Section 3(d) provides that the VA is authorized to accept 
funds from the IHS for reimbursement of the assessed VA co-
    Section 3(e) directs that no later than 90 days after the 
enactment of S. 304, the IHS and the VA report to Congress:
           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 2011 to 
        2016; and
           provide 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 


    The following cost estimate, as provided by the 
Congressional Budget Office, dated May 2, 2017.

Hon. John Hoeven,
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. 304, 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 
                                                        Keith Hall.

S. 304--Tribal Veterans Health Care Enhancement Act

    S. 304 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 them 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 based on their VA priority group. Using 
information provided by the VA regarding the collection of 
copayments, CBO estimates that S. 304 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. 
304 would not affect direct spending or revenues; therefore, 
pay-as-you-go procedures do not apply.
    CBO estimates that enacting S. 304 would not increase net 
direct spending or on-budget deficits in any of the four 
consecutive 10-year periods beginning in 2028.
    S. 304 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 that would authorize IHS 
to make 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. 304.


    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. 304 will 
have a minimal impact on regulatory or paperwork requirements.


    On January 31, 2017, the Committee on Indian Affairs 
unanimously approved a motion to waive the Cordon rule. Thus, 
in the opinion of the committee, it is necessary to dispense 
with subsection 12 of rule XXVI of the Standing Rules of the 
Senate in order to expedite the business of the Senate.