	Introduction

On March 23, 2010, President Obama signed into law a comprehensive health care reform bill, the Patient Protection and Affordable Care Act (ACA), which, among other things, reauthorizes the Indian Health Care Improvement Act (IHCIA ). This report, one of a series of CRS products on the ACA, summarizes some of the key changes made in the reauthorization of IHCIA. In addition, the report summarizes other ACA provisions related to American Indians and Alaska Natives enrolled in and receiving services from Medicare, Medicaid, and the State Children's Health Insurance Program (CHIP)—also called SSA health benefit programs. It also discusses ACA changes to private health insurance coverage that may affect American Indians' and Alaska Natives' access to private health insurance coverage. Another report, CRS Report R41630, The Indian Health Care Improvement Act Reauthorization and Extension as Enacted by the ACA: Detailed Summary and Timeline , by [author name scrubbed], provides a detailed section-by-section summary of the IHCIA Reauthorization and Extension Act of 2009. Indian Health Care Improvement Act

The Indian Health Care Improvement Act, as passed in 1976 and subsequently amended, authorized many specific IHS activities, set out the national policy for health services administered to Indians, and declared that it was a federal goal to improve the health status and conditions of the IHS service population. IHCIA also authorized direct collections from Medicare, Medicaid, and other third-party insurers for American Indians and Alaska Natives receiving services at facilities operated by the IHS, an IT, or a TO. Prior to reauthorizing IHCIA in the ACA, lawmakers introduced multiple reauthorization bills. Despite the lapse in authorization of appropriations during this period, Congress continued to appropriate funds for IHCIA programs. Title II, "Role of Public Programs," Subtitle K, "Protections for American Indians and Alaska Natives," contains provisions related to American Indians and Alaska Natives in SSA health benefit programs and in the private health insurance exchange established by the ACA. In addition, other sections of the ACA include changes related to private insurance that may affect American Indians and Alaska Natives. In addition, the bill maintains a number of IHCIA-defined terms. Expanded Access to UIOs and TOs: Permits TOs and UIOs to apply for grant and contract programs for which these entities were previously not eligible. Behavioral Health Programs: Expands mental health services to create a comprehensive behavioral health and treatment program. Office of Direct Service Tribes: Requires that IHS establish an Office of Direct Service Tribes to serve tribes that receive their health care and other services directly from IHS rather than through facilities or programs operated by ITs or TOs. Nevada Area Office : Requires a plan to establish a new area office to serve tribes in Nevada. The ACA also includes a new provision that authorizes the Secretary to accept funding from any other source for facilities construction. ACA Private Health Insurance Changes

The ACA makes significant changes to private health insurance coverage that may affect certain American Indians and Alaska Natives. This subtitle does the following: (1) it designates facilities operated by IHS, an IT, a TO, or a UIO as the payor of last resort notwithstanding federal or state law to the contrary; (2) it includes IHS, ITs, and TOs as entities that are permitted to determine Medicaid and CHIP eligibility; (3) it prohibits cost sharing for Indians whose incomes are at or below 300% of the federal poverty level and who are enrolled in a qualified health benefit plan in the individual market through the exchange (as established by the ACA), and (4) it extends the period for which IHS, IT, and TO services are reimbursed by Medicare Part B for all services, indefinitely, beginning January 1, 2010. Prior to the ACA, authority for these facilities to receive Medicare Part B reimbursements for certain specified services had expired on January 1, 2010.
On March 23, 2010, President Obama signed into law a comprehensive health care reform bill, the Patient Protection and Affordable Care Act (ACA; P.L. 111-148). The law, among other things, reauthorizes the Indian Health Care Improvement Act (P.L. 94-437, IHCIA), which authorizes many programs and services provided by the Indian Health Service (IHS). In addition, it makes several changes that may affect American Indians and Alaska Natives enrolled in and receiving services from the Medicare, Medicaid, and State Children's Health Insurance Program (CHIP)—also called Social Security Act (SSA) health benefit programs. The ACA also includes changes to private health insurance that may affect American Indians and Alaska Natives and may affect tribes that offer private health insurance.
IHCIA authorizes many IHS programs and services, sets out the national policy for health services administered to Indians, and articulates the federal goal of ensuring the highest possible health status for Indians, including urban Indians. In addition, it authorizes direct collections from Medicare, Medicaid, and other third-party insurers. Prior to the ACA, IHCIA was last reauthorized in FY2000, although programs continued to receive appropriations in later years. The ACA reauthorizes IHCIA and extends authorizations of appropriations for IHCIA programs indefinitely. It amends a number of sections of IHCIA in general, to permit tribal organizations (TOs) and urban Indian organizations (UIOs) to apply for contract and grant programs for which they were not previously eligible; to create new mental health prevention and treatment programs; and to require demonstration projects to construct modular and mobile health facilities in order to expand health services available through IHS, Indian Tribes (ITs), and TOs. It also made several organizational changes to IHS. It requires IHS to establish an Office of Direct Service Tribes to serve tribes that receive their health care and other services directly from IHS as opposed to receiving services through IHS-funded facilities or programs operated by ITs or TOs. In addition, the law requires IHS to develop a plan to establish a new area office to serve tribes in Nevada and requires the Secretary of the Department of Health and Human Services (HHS) to appoint a new IHS Director of HIV/AIDS Prevention and Treatment.
In addition to reauthorizing IHCIA, the ACA includes a number of provisions that may affect American Indians and Alaska Natives who have private insurance coverage or who receive services through SSA health benefit programs. With regard to private insurance coverage, the ACA provides a special enrollment period for American Indians and Alaska Natives who may enroll in private insurance offered through an exchange and exempts certain American Indians and Alaska Natives from the requirement to obtain insurance coverage. Under regulation, additional American Indians and Alaska Natives may also be exempt from the ACA requirement to obtain insurance coverage. With regard to SSA health benefit programs, the new law permits specified Indian entities to determine Medicaid and CHIP eligibility and extends the period during which IHS, IT, and TO services are reimbursed for all Medicare Part B services, indefinitely, beginning January 1, 2010. Prior to the ACA, authority for these facilities to receive Medicare Part B reimbursements for certain specified services had expired on January 1, 2010.
This report, one of a series of CRS products on the ACA, summarizes some of the key changes made in the reauthorization of IHCIA and summarizes other changes included in the ACA that may affect American Indian and Alaska Native health and health care. Another report, CRS Report R41630, The Indian Health Care Improvement Act Reauthorization and Extension as Enacted by the ACA: Detailed Summary and Timeline, by [author name scrubbed], provides a detailed section-by-section summary of the IHCIA Reauthorization and Extension Act of 2009.