ceive Medicaid benefits through managed care arrangements. Those changes include:

• Managed care organizations (MCOS) would have to pay Indian health programs at least the rates used for non-preferred providers. States also would have the option of making those payments directly to Indian health programs.

• MCOS would have to accept claims submitted by Indian health programs instead of requiring enrollees to submit claims personally.

Some requirements that MCOS must now meet to participate in Medicaid would be waived or modified for Indian health programs that seek to operate as MCOS. (For example, MCOs run by Indian health programs would be able to limit enrollment to Indians only.)

⚫ States would be required to offer contracts to Indian health programs seeking to operate their own MCOS.

Based on administrative data on Medicaid enrollment and spending for Indians who receive benefits via managed care, CBO estimates that those provisions would increase federal Medicaid spending by $3 million in 2008 and $45 million over the 2008-2017 period. We anticipate that the additional costs would be relatively modest because some states already use similar rules in their Medicaid managed care programs and Indian health programs would have a limited interest in participating as MCOS.

Estimated impact on state, local, and tribal governments: The legislation contains no intergovernmental mandates as defined in UMRA. The bill would impose new rules on state Medicaid programs and prohibit states from imposing cost-sharing requirements or charging premiums to Indians who receive services or benefits through an Indian health program. Some tribal entities, particularly those operating managed care systems, may realize some savings as a result of these provisions. CBO estimates that the new requirements in the bill would result in additional spending by states of about $78 million over the 2008-2017 period.

Those requirements, however, would not be intergovernmental mandates as defmed by UMRA because Medicaid provides states with significant flexibility to make programmatic adjustments to accommodate the changes. UMRA makes special provision for identifying intergovernmental mandates in legislation affecting large entitlement grant programs (those that provide more than $500 million annually to state, local, or tribal governments), including Medicaid. If a legislative proposal would increase the stringency of conditions of assistance, or cap or decrease the amount of federal funding for the program, such a change would be considered an intergovernmental mandate only if the state, local, or tribal government lacks authority to amend its fmancial or programmatic responsibilities to continue providing required services.

The legislation would reauthorize and expand grant and assistance programs available to Indian tribes, tribal organizations, and urban Indian organizations for a range of health care programs, including prevention, treatment, and ongoing care. The bill also would allow IHS and tribal entities to share facilities, and it would authorize joint ventures between IHS and Indian tribes or tribal organizations for the construction and operation of health facilities. Finally, the bill would authorize funding for a variety of health

services including hospice care, long-term care, public health services, and home and community-based services that would benefit tribal governments.

Estimated impact on the private sector: This legislation contains no private-sector mandates as defined in UMRA.

Previous CBO estimate: On September 11, 2007, CBO issued revised cost estimates for S. 1200, the Indian Health Care Improvement Act Amendments of 2007, as ordered reported by the Senate Committee on Indian Affairs on May 10, 2007, and H.R. 1328, the Indian Health Care Improvement Act Amendments of 2007, as ordered reported by the House Committee on Natural Resources on April 25, 2007. Those bills contain the same Medicaid provisions as the Finance Committee's legislation, and CBO's estimates for them are identical.

Estimate prepared by: Federal Costs: Eric Rollins and Jeanne De Sa; Impact on State, Local, and Tribal Governments: Lisa RamirezBranum; Impact on the Private Sector: Paige Shevlin.

Estimate approved by: Keith J. Fontenot, Assistant Director for Health and Human Resources, Budget Analysis Division.

IV. REGULATORY IMPACT AND OTHER MATTERS

A. REGULATORY IMPACT

Pursuant to paragraph 11(b) of rule XXVI of the Standing Rules of the Senate, the Committee makes the following statement concerning the regulatory impact that might be incurred in carrying out the provisions of the bill as amended.

Impact on individuals and businesses

The provisions of the bill are not expected to impose additional administrative requirements or regulatory burdens on individuals or businesses.

Impact on personal privacy and paperwork

The provisions of the bill do not reduce personal privacy.

B. UNFUNDED MANDATES STATEMENT

This information is provided in accordance with section 423 of the Unfunded Mandates Reform Act of 1995 (P.L. 104-4).

The Committee has determined that the provisions of the bill contain no Federal private sector mandates.

The Committee has determined that the provisions of the bill do not impose a Federal intergovernmental mandate on State, local, or tribal governments.

V. VOTES OF THE COMMITTEE

In compliance with paragraph 7(b) of rule XXVI of the Standing Rules of the Senate, the following statements are made concerning the votes taken on the Committee's consideration of the bill.

Motion to report the bill

The bill was ordered favorably reported by voice vote, a quorum being present, on September 12, 2007.

Votes on amendments

No amendments were offered and voted upon.

VI. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

Pursuant to the requirements of paragraph 12 of rule XXVI of the Standing Rules of the Senate, 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):

TITLE XI-GENERAL PROVISIONS, PEER REVIEW, AND ADMINISTRATIVE SIMPLIFICATION

EXCLUSION OF CERTAIN INDIVIDUALS AND ENTITIES FROM PARTICIPATION IN MEDICARE AND STATE HEALTH CARE PROGRAMS

SEC. 1128. (a) MANDATORY EXCLUSION.-The Secretary shall exclude the following individuals and entities from participation in any Federal health care program (as defined in section 1128B(f)):

(k) ADDITIONAL EXCLUSION WAIVER AUTHORITY FOR AFFECTED INDIAN HEALTH PROGRAMS.-In addition to the authority granted the Secretary under subsections (c)(3)(B) and (d)(3)(B) to waive an exclusion under subsection (a)(1), (a)(3), (a)(4), or (b), the Secretary may, in the case of an Indian Health Program, waive such an exclusion upon the request of the administrator of an affected Indian Health Program (as defined in section 4 of the Indian Health Care Improvement Act) who determines that the exclusion would impose a hardship on individuals entitled to benefits under or enrolled in a Federal health care program.

(1) knowingly and willfully makes or causes to be made any false statement or representation of a material fact in any application for any benefit or payment under a Federal health care program (as defined in subsection (f)),

(b)(1) Whoever knowingly and willfully solicits or receives any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind—

(4) Subject to such conditions as the Secretary may promulgate from time to time as necessary to prevent fraud and abuse, for purposes of paragraphs (1) and (2) and section 1128A(a), the following transfers shall not be treated as remuneration:

(A) TRANSFERS BETWEEN INDIAN HEALTH PROGRAMS, INDIAN TRIBES, TRIBAL ORGANIZATIONS, AND URBAN INDIAN ORGANIZATIONS.-Transfers of anything of value between or among an Indian Health Program, Indian Tribe, Tribal Organization, or Urban Indian Organization, that are made for the purpose of providing necessary health care items and services to any patient served by such Program, Tribe, or Organization and that consist of

(i) services in connection with the collection, transport, analysis, or interpretation of diagnostic specimens or test data;

(ii) inventory or supplies;

(iii) staff; or

(iv) a waiver of all or part of premiums or cost sharing. (B) TRANSFERS BETWEEN INDIAN HEALTH PROGRAMS, INDIAN TRIBES, TRIBAL ORGANIZATIONS, OR URBAN INDIAN ORGANIZATIONS AND PATIENTS.-Transfers of anything of value between an Indian Health Program, Indian Tribe, Tribal Organization, or Urban Indian Organization and any patient served or eligible for service from an Indian Health Program, Indian Tribe, Tribal Organization, or Urban Indian Organization, including any patient served or eligible for service pursuant to section 807 of the Indian Health Care Improvement Act, but only if such transfers

(i) consist of expenditures related to providing transportation for the patient for the provision of necessary health care items or services, provided that the provision of such transportation is not advertised, nor an incentive of which the value is disproportionately large in relationship to the value of the health care item or service (with respect to the value of the item or service itself or, for preventative items or services, the future health care costs reasonably expected to be avoided);

(ii) consist of expenditures related to providing housing to the patient (including a pregnant patient) and immediate family members or an escort necessary to assuring the timely provision of health care items and services to the patient, provided that the provision of such housing is not advertised nor an incentive of which the value is disproportionately large in relationship to the value of the health care item or service (with respect to the value of the item or service itself or, for preventative items or services, the future health care costs reasonably expected to be avoided); or

(iii) are for the purpose of paying premiums or cost sharing on behalf of such a patient, provided that the_making of such payment is not subject to conditions other than con

ditions agreed to under a contract for the delivery of contract health services.

(C) CONTRACT HEALTH SERVICES.—A transfer of anything of value negotiated as part of a contract entered into between an Indian Health Program, Indian Tribe, Tribal Organization, Urban Indian Organization, or the Indian Health Service and a contract care provider for the delivery of contract health services authorized by the Indian Health Service, provided that(i) such a transfer is not tied to volume or value of referrals or other business generated by the parties; and

(ii) any such transfer is limited to the fair market value of the health care items or services provided or, in the case of a transfer of items or services related to preventative care, the value of the future health care costs reasonably expected to be avoided.

(D) OTHER TRANSFERS.-Any other transfer of anything of value involving an Indian Health Program, Indian Tribe, Tribal Organization, or Urban Indian Organization, or a patient served or eligible for service from an Indian Health Program, Indian Tribe, Tribal Organization, or Urban Indian Organization, that the Secretary, in consultation with the Attorney General, determines is appropriate, taking into account the special circumstances of such Indian Health Programs, Indian Tribes, Tribal Organizations, and Urban Indian Organizations, and of patients served by such Programs, Tribes, and Organizations.

[NATIONAL COMMISSION ON CHILDREN

[SEC. 1139. (a)(1) There is hereby established a commission to be known as the National Commission on Children (in this section referred to as the "Commission").

[(b)(1) The Commission shall consist of

[(A) 12 members to be appointed by the President,

[(B) 12 members to be appointed by the Speaker of the House of Representatives, and

[(C) 12 members to be appointed by the President pro tempore of the Senate.

[(2) The President, the Speaker, and the President pro tempore shall each appoint as members of the Commission—

[(A) 4 individuals who—

[(i) are representatives of organizations providing services to children,

[(ii) are involved in activities on behalf of children, or [(iii) have engaged in academic research with respect to the problems and needs of children,

[(B) 4 individuals who are elected or appointed public officials (at the Federal, State, or local level) involved in issues and programs relating to children, and

[(C) 4 individuals who are parents or representatives of parents or parents' organizations.

[(3) The appointments made pursuant to subparagraphs (B) and (C) of paragraph (1) shall be made in consultation with the chairmen of committees of the House of Representatives and the Senate, respectively, having jurisdiction over relevant Federal programs.