Indian Health Care Improvement Act
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Sec. 4. [25 U.S.C. 1603] For purposes of this Act—
(a) “Secretary”, unless otherwise designated, means the Secretary of Health and Human Services.
(b) “Service” means the Indian Health Service.
(c) “Indians” or “Indian”, unless otherwise designated, means any person who is a member of an Indian tribe, as defined in subsection (d) hereof, except that, for the purpose of sections 102 and 103, such terms shall mean any individual who (1), irrespective of whether he or she lives on or near a reservation, is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member, or (2) is an Eskimo or Aleut or other Alaska Native, or (3) is considered by the Secretary of the Interior to be an Indian for any purpose, or (4) is determined to be an Indian under regulations promulgated by the Secretary.
(d) “Indian tribe” means any Indian tribe, band, nation, or other organized group or community, including any Alaska Native village or group or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688), which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.
(e) “Tribal organization” means the elected governing body of any Indian tribe or any legally established organization of Indians which is controlled by one or more such bodies or by a board of directors elected or selected by one or more such bodies (or elected by the Indian population to be served by such organization) and which includes the maximum participation of Indians in all phases of its activities.
(f) “Urban Indian” means any individual who resides in an urban center, as defined in subsection (g) hereof, and who meets one or more of the four criteria in subsection (c)(1) through (4) of this section.
(g) “Urban center” means any community which has a sufficient urban Indian population with unmet health needs to warrant assistance under title V, as determined by the Secretary.
(h) “Urban Indian organization” means a nonprofit corporate body situated in an urban center, governed by an urban Indian controlled board of directors, and providing for the maximum participation of all interested Indian groups and individuals, which body is capable of legally cooperating with other public and private entities for the purpose of performing the activities described in section 503(a).
(i) “Area office” means an administrative entity including a program office, within the Indian Health Service through which services and funds are provided to the service units within a defined geographic area.
(j) “Service unit” means—
(1) an administrative entity within the Indian Health Service, or
(2) a tribe or tribal organization operating health care programs or facilities with funds from the Service under the Indian Self-Determination Act,
through which services are provided, directly or by contract, to the eligible Indian population within a defined geographic area.
(k) “Health promotion” includes—
(1) cessation of tobacco smoking,
(2) reduction in the misuse of alcohol and drugs,
(3) improvement of nutrition,
(4) improvement in physical fitness,
(5) family planning,
(6) control of stress, and
(7) pregnancy and infant care (including prevention of fetal alcohol syndrome).
(l) “Disease prevention” includes—
(2) control of high blood pressure,
(3) control of sexually transmittable diseases,
(4) prevention and control of diabetes,
(5) control of toxic agents,
(6) occupational safety and health,
(7) accident prevention,
(8) fluoridation of water, and
(9) control of infectious agents.
(m) “Service area” means the geographical area served by each area office.
(n) “Health profession” means family medicine, internal medicine, pediatrics, geriatric medicine, obstetrics and gynecology, podiatric medicine, nursing, public health nursing, dentistry, psychiatry, osteopathy, optometry, pharmacy, psychology, public health, social work, marriage and family therapy, chiropractic medicine, environmental health and engineering, and allied health professions.
(o) “Substance abuse” includes inhalant abuse.
(p) “FAE” means fetal alcohol effect.
(q) “FAS” means fetal alcohol syndrome.
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INDIAN HEALTH SERVICE LOAN REPAYMENT PROGRAM
Sec. 21. [25 U.S.C. 1616a]
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(l)(1) An individual who has entered into a written contract with the Secretary under this section and who—
(A) is enrolled in the final year of a course of study and who—
(i) fails to maintain an acceptable level of academic standing in the educational institution in which he is enrolled (such level determined by the educational institution under regulations of the Secretary);
(ii) voluntarily terminates such enrollment; or
(iii) is dismissed from such educational institution before completion of such course of study; or
(B) is enrolled in a graduate training program, fails to complete such training program, and does not receive a waiver from the Secretary under subsection (b)(1)(B)(ii),
shall be liable, in lieu of any service obligation arising under such contract, to the United States for the amount which has been paid on such individual’s behalf under the contract.
(2) If, for any reason not specified in paragraph (1), an individual breaches his written contract under this section by failing either to begin, or complete, such individual’s period of obligated service in accordance with subsection (f), the United States shall be entitled to recover from such individual an amount to be determined in accordance with the following formula:
(A) “A” is the amount the United States is entitled to recover;
(B) “Z” is the sum of the amounts paid under this section to, or on behalf of, the individual and the interest on such amounts which would be payable if, at the time the amounts were paid, they were loans bearing interest at the maximum legal prevailing rate, as determined by the Treasurer of the United States;
(C) “t” is the total number of months in the individual’s period of obligated service in accordance with subsection (f); and
(D) “s” is the number of months of such period served by such individual in accordance with this section.
Amounts not paid within such period shall be subject to collection through deductions in Medicare payments pursuant to section 1892 of the Social Security Act.
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(c) [42 U.S.C. 1395qq note] Any payments received for services provided to beneficiaries hereunder shall not be considered in determining appropriations for health care and services to Indians.
(d) [42 U.S.C. 1395qq note] Nothing herein authorizes the Secretary to provide services to an Indian beneficiary with coverage under title XVIII of the Social Security Act, as amended, in preference to an Indian beneficiary without such coverage.
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(c) [42 U.S.C. 1396j note] Notwithstanding any other provision of law, payments to which any facility of the Indian Health Service (including a hospital, intermediate care facility, skilled nursing facility, or any other type of facility which provides services of a type otherwise covered under a State plan for medical assistance approved under title XIX of the Social Security Act) is entitled under such a State plan by reason of section 1911 of such Act shall be placed in a special fund to be held by the Secretary and used by him (to such extent or in such amounts as are provided in appropriation Acts) exclusively for the purpose of making any improvements in the facilities of such Service which may be necessary to achieve compliance with the applicable conditions and requirements of such title. In making payments from such fund, the Secretary shall ensure that each service unit of the Indian Health Service receives at least 50 percent of the amounts to which the facilities of the Indian Health Service, for which such service unit makes collections, are entitled by reason of section 1911 of the Social Security Act, if such amount is necessary for the purpose of making improvements in such facilities in order to achieve compliance with the conditions and requirements of title XIX of the Social Security Act. This subsection shall cease to apply when the Secretary determines and certifies that substantially all of the health facilities of such Service in the United States are in compliance with such conditions and requirements.
(d) [42 U.S.C. 1396j note] Any payments received for services provided recipients hereunder shall not be considered in determining appropriations for the provision of health care and services to Indians.
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Sec. 403. [25 U.S.C. 1671 note] The Secretary shall include in his annual report required by section 701 an accounting on the amount and use of funds made available to the Service pursuant to this title as a result of reimbursements through titles XVIII and XIX of the Social Security Act, as amended.
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TITLE V—HEALTH SERVICES FOR URBAN INDIANS
Sec. 501. [25 U.S.C. 1651] The purpose of this title is to establish programs in urban centers to make health services more accessible to urban Indians.
CONTRACTS WITH, AND GRANTS TO, URBAN INDIAN ORGANIZATIONS
Sec. 502. [25 U.S.C. 1652] Under authority of the Act of November 2, 1921 (25 U.S.C. 13), popularly known as the Snyder Act, the Secretary, through the Service, shall enter into contracts with, or make grants to, urban Indian organizations to assist such organizations in the establishment and administration, within the urban centers in which such organizations are situated, of programs which meet the requirements set forth in this title. The Secretary, through the Service, shall include such conditions as the Secretary considers necessary to effect the purpose of this title in any contract which the Secretary enters into with, or in any grant the Secretary makes to, any urban Indian organization pursuant to this title.
CONTRACTS AND GRANTS FOR THE PROVISION OF HEALTH CARE AND REFERRAL SERVICES
Sec. 503. [25 U.S.C. 1653] (a) Under authority of the Act of November 2, 1921 (25 U.S.C. 13), popularly known as the Snyder Act, the Secretary, through the Service, shall enter into contracts with, or make grants to, urban Indian organizations for the provision of health care and referral services for urban Indians residing in the urban centers in which such organizations are situated. Any such contract or grant shall include requirements that the urban Indian organization successfully undertake to—
(1) estimate the population of urban Indians residing in the urban center in which such organization is situated who are or could be recipients of health care or referral services;
(2) estimate the current health status of urban Indians residing in such urban center;
(3) estimate the current health care needs of urban Indians residing in such urban center;
(4) identify all public and private health services resources within such urban center which are or may be available to urban Indians;
(5) determine the use of public and private health services resources by the urban Indians residing in such urban center;
(6) assist such health services resources in providing services to urban Indians;
(7) assist urban Indians in becoming familiar with and utilizing such health services resources;
(8) provide basic health education, including health promotion and disease prevention education, to urban Indians;
(9) establish and implement training programs to accomplish the referral and education tasks set forth in paragraphs (6) through (8) of this subsection;
(10) identify gaps between unmet health needs of urban Indians and the resources available to meet such needs;
(11) make recommendations to the Secretary and Federal, State, local, and other resource agencies on methods of improving health service programs to meet the needs of urban Indians; and
(12) where necessary, provide, or enter into contracts for the provision of, health care services for urban Indians.
(b) The Secretary, through the Service, shall by regulation prescribe the criteria for selecting urban Indian organizations to enter into contracts or receive grants under this section. Such criteria shall, among other factors, include—
(1) the extent of unmet health care needs of urban Indians in the urban center involved;
(2) the size of the urban Indian population in the urban center involved;
(3) the accessibility to, and utilization of, health care services (other than services provided under this title) by urban Indians in the urban center involved;
(4) the extent, if any, to which the activities set forth in subsection (a) would duplicate—
(A) any previous or current public or private health services project in an urban center that was or is funded in a manner other than pursuant to this title; or
(B) any project funded under this title;
(5) the capability of an urban Indian organization to perform the activities set forth in subsection (a) and to enter into a contract with the Secretary or to meet the requirements for receiving a grant under this section;
(6) the satisfactory performance and successful completion by an urban Indian organization of other contracts with the Secretary under this title;
(7) the appropriateness and likely effectiveness of conducting the activities set forth in subsection (a) in an urban center; and
(8) the extent of existing or likely future participation in the activities set forth in subsection (a) by appropriate health and health-related Federal, State, local, and other agencies.
(c) The Secretary, acting through the Service, shall facilitate access to, or provide, health promotion and disease prevention services for urban Indians through grants made to urban Indian organizations administering contracts entered into pursuant to this section or receiving grants under subsection (a).
(d)(1) The Secretary, acting through the Service, shall facilitate access to, or provide, immunization services for urban Indians through grants made to urban Indian organizations administering contracts entered into pursuant to this section or receiving grants under subsection (a).
(2) In making any grant to carry out this subsection, the Secretary shall take into consideration—
(A) the size of the urban Indian population to be served;
(B) the immunization levels of the urban Indian population, particularly the immunization levels of infants, children, and the elderly;
(C) the utilization by the urban Indians of alternative resources from State and local governments for no-cost or low-cost immunization services to the general population; and
(D) the capability of the urban Indian organization to carry out services pursuant to this subsection.
(3) For purposes of this subsection, the term “immunization services” means services to provide without charge immunizations against vaccine-preventable diseases.
(e)(1) The Secretary, acting through the Service, shall facilitate access to, or provide, mental health services for urban Indians through grants made to urban Indian organizations administering contracts entered into pursuant to this section or receiving grants under subsection (a).
(2) A grant may not be made under this subsection to an urban Indian organization until that organization has prepared, and the Service has approved, an assessment of the mental health needs of the urban Indian population concerned, the mental health services and other related resources available to that population, the barriers to obtaining those services and resources, and the needs that are unmet by such services and resources.
(3) Grants may be made under this subsection—
(A) to prepare assessments required under paragraph (2);
(B) to provide outreach, educational, and referral services to urban Indians regarding the availability of direct mental health services, to educate urban Indians about mental health issues and services, and effect coordination with existing mental health providers in order to improve services to urban Indians;
(C) to provide outpatient mental health services to urban Indians, including the identification and assessment of illness, therapeutic treatments, case management, support groups, family treatment, and other treatment; and
(D) to develop innovative mental health service delivery models which incorporate Indian cultural support systems and resources.
(f)(1) The Secretary, acting through the Service, shall facilitate access to, or provide, services for urban Indians through grants to urban Indian organizations administering contracts entered into pursuant to this section or receiving grants under subsection (a) to prevent and treat child abuse (including sexual abuse) among urban Indians.
(2) A grant may not be made under this subsection to an urban Indian organization until that organization has prepared, and the Service has approved, an assessment that documents the prevalence of child abuse in the urban Indian population concerned and specifies the services and programs (which may not duplicate existing services and programs) for which the grant is requested.
(3) Grants may be made under this subsection—
(A) to prepare assessments required under paragraph (2);
(B) for the development of prevention, training, and education programs for urban Indian populations, including child education, parent education, provider training on identification and intervention, education on reporting requirements, prevention campaigns, and establishing service networks of all those involved in Indian child protection; and
(C) to provide direct outpatient treatment services (including individual treatment, family treatment, group therapy, and support groups) to urban Indians who are child victims of abuse (including sexual abuse) or adult survivors of child sexual abuse, to the families of such child victims, and to urban Indian perpetrators of child abuse (including sexual abuse);
(4) In making grants to carry out this subsection, the Secretary shall take into consideration—
(A) the support for the urban Indian organization demonstrated by the child protection authorities in the area, including committees or other services funded under the Indian Child Welfare Act of 1978 (25 U.S.C. 1901 et seq.), if any;
(B) the capability and expertise demonstrated by the urban Indian organization to address the complex problem of child sexual abuse in the community; and
(C) the assessment required under paragraph (2).
CONTRACTS AND GRANTS FOR THE DETERMINATION OF UNMET HEALTH CARE NEEDS
Sec. 504. [25 U.S.C. 1654] (a) Under authority of the Act of November 2, 1921 (25 U.S.C. 13), popularly known as the Snyder Act, the Secretary, through the Service, may enter into contracts with, or make grants to, urban Indian organizations situated in urban centers for which contracts have not been entered into, or grants have not been made, under section 503. The purpose of a contract or grant made under this section shall be the determination of the matters described in subsection (b)(1) in order to assist the Secretary in assessing the health status and health care needs of urban Indians in the urban center involved and determining whether the Secretary should enter into a contract or make a grant under section 503 with respect to the urban Indian organization which the Secretary has entered into a contract with, or made a grant to, under this section.
(b) Any contract entered into, or grant made by the Secretary under this section shall include requirements that—
(1) the urban Indian organization successfully undertake to—
(A) document the health care status and unmet health care needs of urban Indians in the urban center involved; and
(B) with respect to urban Indians in the urban center involved, determine the matters described in clauses (2), (3), (4), and (8) of section 503(b); and
(2) the urban Indian organization complete performance of the contract, or carry out the requirements of the grant, within one year after the date on which the Secretary and such organization enter into such contract, or within one year after such organization receives such grant, whichever is applicable.
(c) The Secretary may not renew any contract entered, or grant made into under this section.
Sec. 505. [25 U.S.C. 1655] (a) The Secretary, through the Service, shall develop procedures to evaluate compliance with grant requirements under this title and compliance with, and performance of contracts entered into by urban Indian organizations under this title. Such procedures shall include provisions for carrying out the requirements of this section.
(b) The Secretary, through the Service, shall conduct an annual onsite evaluation of each urban Indian organization which has entered into a contract or received a grant under section 503 for purposes of determining the compliance of such organization with, and evaluating the performance of such organization under, such contract or the terms of such grant.
(c) If, as a result of the evaluations conducted under this section, the Secretary determines that an urban Indian organization has not complied with the requirements of a grant or complied with or satisfactorily performed a contract under section 503, the Secretary shall, prior to renewing such contract or grant, attempt to resolve with such organization the areas of noncompliance or unsatisfactory performance and modify such contract or grant to prevent future occurrences of such noncompliance or unsatisfactory performance. If the Secretary determines that such noncompliance or unsatisfactory performance cannot be resolved and prevented in the future, the Secretary shall not renew such contract or grant with such organization and is authorized to enter into a contract or make a grant under section 503 with another urban Indian organization which is situated in the same urban center as the urban Indian organization whose contract or grant is not renewed under this section.
(d) In determining whether to renew a contract or grant with an urban Indian organization under section 503 which has completed performance of a contract or grant under section 504, the Secretary shall review the records of the urban Indian organization, the reports submitted under section 507, and, in the case of a renewal of a contract or grant under section 503, shall consider the results of the onsite evaluations conducted under subsection (b).
OTHER CONTRACT AND GRANT REQUIREMENTS
Sec. 506. [25 U.S.C. 1656] (a) Contracts with urban Indian organizations entered into pursuant to this title shall be in accordance with all Federal contracting laws and regulations except that, in the discretion of the Secretary, such contracts may be negotiated without advertising and need not conform to the provisions of the Act of August 24, 1935 (40 U.S.C. 270a, et seq.).
(b) Payments under any contracts or grants pursuant to this title may be made in advance or by way of reimbursement and in such installments and on such conditions as the Secretary deems necessary to carry out the purposes of this title.
(c) Notwithstanding any provision of law to the contrary, the Secretary may, at the request or consent of an urban Indian organization, revise or amend any contract entered into by the Secretary with such organization under this title as necessary to carry out the purposes of this title.
(d) In connection with any contract or grant entered into pursuant to this title, the Secretary may permit an urban Indian organization to utilize, in carrying out such contract or grant, existing facilities owned by the Federal Government within the Secretary’s jurisdiction under such terms and conditions as may be agreed upon for the use and maintenance of such facilities.
(e) Contracts with, or grants, urban Indian organizations and regulations adopted pursuant to this title shall include provisions to assure the fair and uniform provision to urban Indians of services and assistance under such contracts or grants by such organizations.
(f) Urban Indians, as defined in section 4(f) of this Act, shall be eligible for health care or referral services provided pursuant to this title.
REPORTS AND RECORDS
Sec. 507. [25 U.S.C. 1657] (a) For each fiscal year during which an urban Indian organization receives or expends funds pursuant to a contract entered into, or a grant received, pursuant to this title, such organization shall submit to the Secretary a quarterly report including—
(1) in the case of a contract or grant under section 503, information gathered pursuant to clauses (10) and (11) of subsection (a) of such section;
(2) information on activities conducted by the organization pursuant to the contract or grant;
(3) an accounting of the amounts and purposes for which Federal funds were expended; and
(4) such other information as the Secretary may request.
(b) The reports and records of the urban Indian organization with respect to a contract or grant under this title shall be subject to audit by the Secretary and the Comptroller General of the United States.
(c) The Secretary shall allow as a cost of any contract or grant entered into under section 503 the cost of an annual private audit conducted by a certified public accountant.
(d)(1) The Secretary, acting through the Service, shall submit a report to the Congress not later than March 31, 1992, evaluating—
(A) the health status of urban Indians;
(B) the services provided to Indians through this title;
(C) areas of unmet needs in urban areas served under this title; and
(D) areas of unmet needs in urban areas not served under this title.
(2) In preparing the report under paragraph (1), the Secretary shall consult with urban Indian health providers and may contract with a national organization representing urban Indian health concerns to conduct any aspect of the report.
(3) The Secretary and the Secretary of the Interior shall—
(A) assess the status of the welfare of urban Indian children, including the volume of child protection cases, the prevalence of child sexual abuse, and the extent of urban Indian coordination with tribal authorities with respect to child sexual abuse; and
(B) submit a report on the assessment required under subparagraph (A), together with recommended legislation to improve Indian child protection in urban Indian populations, to the Congress no later than March 31, 1992.
LIMITATION ON CONTRACT AUTHORITY
Sec. 508. [25 U.S.C. 1658] The authority of the Secretary to enter into contracts under this title shall be to the extent, and in an amount, provided for in appropriation Acts.
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Sec. 801. [25 U.S.C. 1671] The President shall, at the time the budget is submitted under section 1105 of title 31, United States Code, for each fiscal year transmit to the Congress a report containing—
(1) a report on the progress made in meeting the objectives of this Act, including a review of programs established or assisted pursuant to this Act and an assessment and recommendations of additional programs or additional assistance necessary to, at a minimum, provide health services to Indians, and ensure a health status for Indians, which are at a parity with the health services available to and the health status of, the general population;
(2) a report on whether, and to what extent, new national health care programs, benefits, initiatives, or financing systems have had an impact on the purposes of this Act and any steps that the Secretary may have taken to consult with Indian tribes to address such impact;
(3) a report on the use of health services by Indians—
(A) on a national and area or other relevant geographical basis;
(B) by gender and age;
(C) by source of payment and type of service; and
(D) comparing such rates of use with rates of use among comparable non-Indian populations.
(4) a separate statement which specifies the amount of funds requested to carry out the provisions of section 201;
(5) a separate statement of the total amount obligated or expended in the most recently completed fiscal year to achieve each of the objectives described in section 814, relating to infant and maternal mortality and fetal alcohol syndrome;
(6) the reports required by sections 3(d), 108(n), 203(b), 209(j), 301(c), 302(g), 305(a)(3), 403, 708(e), and 817(a), and 822(f);
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Sec. 802. [25 U.S.C. 1672] Prior to any revision of or amendment to rules or regulations promulgated pursuant to this Act, the Secretary shall consult with Indian tribes and appropriate national or regional Indian organizations and shall publish any proposed revision or amendment in the Federal Register not less than sixty days prior to the effective date of such revision or amendment in order to provide adequate notice to, and receive comments from, other interested parties.
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LIMITATION ON USE OF FUNDS APPROPRIATED TO THE INDIAN HEALTH SERVICE
Sec. 806. [25 U.S.C. 1676] (a) HHS Appropriations.—Any limitation on the use of funds contained in an Act providing appropriations for the Department of Health and Human Services for a period with respect to the performance of abortions shall apply for that period with respect to the performance of abortions using funds contained in an Act providing appropriations for the Indian Health Service.
(b) Limitations Pursuant to Other Federal Law.—Any limitation pursuant to other Federal laws on the use of Federal funds appropriated to the Service shall apply with respect to the performance or coverage of abortions.
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HEALTH SERVICES FOR INELIGIBLE PERSONS
Sec. 813. [25 U.S.C. 1680c]
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(2)(A) Persons receiving health services provided by the Service by reason of this subsection shall be liable for payment of such health services under a schedule of charges prescribed by the Secretary which, in the judgment of the Secretary, results in reimbursement in an amount not less than the actual cost of providing the health services. Notwithstanding section 1880(c) of the Social Security Act, section 402(a) of this Act, or any other provision of law, amounts collected under this subsection, including medicare or medicaid reimbursements under titles XVIII and XIX of the Social Security Act, shall be credited to the account of the facility providing the service and shall be used solely for the provision of health services within that facility. Amounts collected under this subsection shall be available for expenditure within such facility for not to exceed one fiscal year after the fiscal year in which collected.
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[Internal References.—SSAct §§511(k)(3), 1880(a) and (d), 1905(b), 1911(a), 1928(c) and (h), and 2102(b) cite the Indian Health Care Improvement Act. SSAct §§1861, 1880, 1892, 1902, and 1911 headings have footnotes referring to P.L. 94-437. P.L. 78-410, §330(c) (this volume) cites the Indian Health Care Improvement Act (Title V).]
 P.L. 102-573, §701(d), deemed the reference to §701 as a reference to §801.