[Congressional Bills 110th Congress]
[From the U.S. Government Publishing Office]
[H.R. 7114 Introduced in House (IH)]







110th CONGRESS
  2d Session
                                H. R. 7114

To amend title XVIII of the Social Security Act to provide certain high 
cost Medicare beneficiaries suffering from multiple chronic conditions 
 with access to Independence at Home services in lower cost treatment 
 settings, such as their residences, under a plan of care developed by 
    an Independence at Home physician or Independence at Home nurse 
                             practitioner.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           September 26, 2008

  Mr. Markey introduced the following bill; which was referred to the 
Committee on Ways and Means, and in addition to the Committee on Energy 
    and Commerce, for a period to be subsequently determined by the 
  Speaker, in each case for consideration of such provisions as fall 
           within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
To amend title XVIII of the Social Security Act to provide certain high 
cost Medicare beneficiaries suffering from multiple chronic conditions 
 with access to Independence at Home services in lower cost treatment 
 settings, such as their residences, under a plan of care developed by 
    an Independence at Home physician or Independence at Home nurse 
                             practitioner.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Independence at Home Act of 2008''.

SEC. 2. FINDINGS.

    Congress makes the following findings:
            (1) According to the November 2007 Congressional Budget 
        Office Long Term Outlook for Health Care Spending, unless 
        changes are made to the way health care is delivered, growing 
        demand for resources caused by rising health care costs and to 
        a lesser extent the nation's expanding elderly population will 
        confront Americans with increasingly difficult choices between 
        health care and other priorities. However, opportunities exist 
        to constrain health care costs without adverse health care 
        consequences.
            (2) Medicare beneficiaries with multiple chronic conditions 
        account for a disproportionate share of Medicare spending 
        compared to their representation in the overall Medicare 
        population, and evidence suggests that such patients often 
        receive poorly coordinated care, including conflicting 
        information from health providers and different diagnoses of 
        the same symptoms.
            (3) People with chronic conditions account for 76 percent 
        of all hospital admissions, 88 percent of all prescriptions 
        filled, and 72 percent of physician visits.
            (4) More than 60 percent of physicians treating patients 
        with chronic conditions believe that their training did not 
        adequately prepare them to coordinate in-home and community 
        services; educate patients with chronic conditions; manage the 
        psychological and social aspects of chronic care; provide 
        effective nutritional guidance; and manage chronic pain.
            (5) Recent studies cited by the Congressional Budget Office 
        found substantial differences among regions of the country in 
        the cost to Medicare of treating beneficiaries with multiple 
        chronic conditions with lower cost regions experiencing better 
        outcomes and lower mortality rates. These studies have 
        suggested that Medicare spending could be reduced by 30 percent 
        if more conservative practice styles were adopted, however, the 
        current Medicare fee-for-service program creates incentives to 
        provide fragmented, high cost health care services.
            (6) Studies show that hospital utilization and emergency 
        room visits for patients with multiple chronic conditions can 
        be reduced and significant savings can be achieved through the 
        use of interdisciplinary teams of health care professionals 
        caring for patients in their places of residence.
            (7) The Independence at Home program, designed to fund 
        better health care and improved health care technology through 
        savings it achieves, uses a patient-centered health care 
        delivery model to permit the growing number of Medicare 
        beneficiaries with multiple chronic conditions to remain as 
        independent as possible for as long as possible and to receive 
        care in a setting that is preferred by the beneficiary involved 
        and the family of such beneficiary.
            (8) The Independence at Home program begins Medicare reform 
        by creating incentives for practitioners and providers to 
        develop methods and technologies for providing better and lower 
        cost health care to the highest cost Medicare beneficiaries 
        with the greatest incentives provided in the case of highest 
        cost beneficiaries.
            (9) The Independence at Home program incorporates lessons 
        learned from prior demonstration projects and phase I of the 
        Voluntary Chronic Care Improvement program under section 1807 
        of the Social Security Act, enacted in sections 721 and 722 of 
        the Medicare Prescription Drug, Improvement and Modernization 
        Act of 2003 (Public Law 108-173).
            (10) The Independence at Home Act provides for a chronic 
        care coordination demonstration for the highest cost Medicare 
        beneficiaries with multiple chronic conditions that holds 
        providers accountable for quality outcomes, patient 
        satisfaction, and mandatory minimum savings on an annual basis.
            (11) The Independence at Home Act generates savings by 
        providing better, more coordinated care to the highest cost 
        Medicare beneficiaries with multiple chronic conditions, 
        reducing duplicative and unnecessary services, and avoiding 
        unnecessary hospitalizations and emergency room visits.

SEC. 3. ESTABLISHMENT OF VOLUNTARY INDEPENDENCE AT HOME CHRONIC CARE 
              COORDINATION DEMONSTRATION PROJECT UNDER TRADITIONAL 
              MEDICARE FEE-FOR-SERVICE PROGRAM.

    (a) In General.--Title XVIII of the Social Security Act is 
amended--
            (1) by amending subsection (c) of section 1807 (42 U.S.C. 
        1395b-8) to read as follows:
    ``(c) Independence at Home Chronic Care Coordination Demonstration 
Project.--A demonstration project for Independence at Home chronic care 
coordination programs for high cost Medicare beneficiaries with 
multiple chronic conditions is set forth in section 1807A.''; and
            (2) by inserting after section 1807 the following new 
        section:

 ``independence at home chronic care coordination demonstration project

    ``Sec. 1807A.  (a) In General.--
            ``(1) Implementation.--The Secretary shall, where possible, 
        enter into agreements with at least two unaffiliated 
        Independence at Home organizations, as described in this 
        section, to provide chronic care coordination services for a 
        period of three years in each of the 13 highest cost States and 
        the District of Columbia and in 13 additional States that are 
        representative of other regions of the United States. Such 
        organizations shall have documented experience in furnishing 
        the types of services covered by this section to eligible 
        beneficiaries in non-institutional settings using qualified 
        teams of health care professionals that are directed by 
        Independence at Home physicians or Independence at Home nurse 
        practitioners and that use health information technology and 
        individualized plans of care.
            ``(2) Eligibility.--Any organization shall be eligible for 
        an Independence at Home agreement in the developmental phase if 
        it is an Independence at Home organization (as defined in 
        subsection (b)(7)) and has the demonstrated capacity to provide 
        the services covered under this section to the number of 
        eligible beneficiaries specified in subsection (e)(3)(C). No 
        organization shall be prohibited from participating because of 
        its small size as long as it meets the eligibility requirements 
        of this section.
            ``(3) Independent evaluation.--The Secretary shall contract 
        for an independent evaluation of the Independence at Home 
        demonstration project under this section with an interim report 
        to be provided after the first year and a final report to be 
        provided after the third year of the project. Such an 
        evaluation shall be conducted by a contractor with knowledge of 
        chronic care coordination programs for the targeted patient 
        population and demonstrated experience in the evaluation of 
        such programs. Each such report shall include an assessment of 
        the following factors and shall identify the characteristics of 
        individual Independence at Home programs that are the most 
        effective:
                    ``(A) Quality improvement measures.
                    ``(B) Beneficiary, caregiver, and provider 
                satisfaction.
                    ``(C) Health outcomes appropriate for patients with 
                multiple chronic conditions.
                    ``(D) Cost savings to the program under this title.
            ``(4) Agreements.--The Secretary shall enter into 
        agreements, beginning not later than one year after the date of 
        the enactment of this section, with Independence at Home 
        organizations that meet the participation requirements of this 
        section, including minimum performance standards developed 
        under subsection (e)(3), in order to provide access by eligible 
        beneficiaries to Independence at Home programs under this 
        section.
            ``(5) Regulations.--At least three months before entering 
        into the first agreement under this section, the Secretary 
        shall publish in the Federal Register the specifications for 
        implementing this section.
            ``(6) Periodic progress reports.--Semi-annually during the 
        first year in which this section is implemented and annually 
        thereafter during the period of implementation of this section, 
        the Secretary shall submit to the Committees on Ways and Means 
        and Energy and Commerce of the House of Representatives and the 
        Committee on Finance of the Senate a report that describes the 
        progress of implementation of this section and explaining any 
        variation from the Independence at Home program as described in 
        this section.
    ``(b) Definitions.--For purposes of this section:
            ``(1) Activities of daily living.--The term `activities of 
        daily living' means bathing, dressing, grooming, transferring, 
        feeding, or toileting.
            ``(2) Caregiver.--The term `caregiver' means, with respect 
        to an individual with a qualifying functional impairment, a 
        family member, friend, or neighbor who provides assistance to 
        the individual.
            ``(3) Eligible beneficiary.--
                    ``(A) In general.--The term `eligible beneficiary' 
                means, with respect to an Independence at Home program, 
                an individual who--
                            ``(i) is entitled to benefits under part A 
                        and enrolled under part B, but not enrolled in 
                        a plan under part C;
                            ``(ii) has a qualifying functional 
                        impairment and has been diagnosed with two or 
                        more of the chronic conditions described in 
                        subparagraph (C); and
                            ``(iii) within the 12 months prior to the 
                        individual first enrolling with an Independence 
                        at Home program under this section, has 
                        received benefits under this title for services 
                        described in each of clauses (i), (ii) and 
                        (iii) of subparagraph (D).
                    ``(B) Disqualifications.--Such term does not 
                include an individual--
                            ``(i) who is receiving benefits under 
                        section 1881;
                            ``(ii) who is enrolled in a PACE program 
                        under section 1894;
                            ``(iii) who is enrolled in (and is not 
                        disenrolled from) a chronic care improvement 
                        program under section 1807;
                            ``(iv) who within the previous year has 
                        been a resident for more than 90 days in a 
                        skilled nursing facility, a nursing facility 
                        (as defined in section 1919), or any other 
                        facility identified by the Secretary;
                            ``(v) who resides in a setting that 
                        presents a danger to the safety of in-home 
                        health care providers and primary caregivers; 
                        or
                            ``(vi) whose enrollment in an Independence 
                        at Home program the Secretary determines would 
                        be inappropriate.
                    ``(C) Chronic conditions described.--The chronic 
                conditions described in this subparagraph are the 
                following:
                            ``(i) Congestive heart failure.
                            ``(ii) Diabetes.
                            ``(iii) Chronic obstructive pulmonary 
                        disease.
                            ``(iv) Ischemic heart disease.
                            ``(v) Peripheral arterial disease.
                            ``(vi) Stroke.
                            ``(vii) Alzheimer's Disease and other 
                        dementias designated by the Secretary.
                            ``(viii) Pressure ulcers.
                            ``(ix) Hypertension.
                            ``(x) Neurodegenerative diseases designated 
                        by the Secretary which result in high costs 
                        under this title, including amyotropic lateral 
                        sclerosis (ALS), multiple sclerosis, and 
                        Parkinson's disease.
                            ``(xi) Any other chronic condition that the 
                        Secretary identifies as likely to result in 
                        high costs to the program under this title when 
                        such condition is present in combination with 
                        one or more of the chronic conditions specified 
                        in the preceding clauses.
                    ``(D) Services described.--The services described 
                in this subparagraph are the following:
                            ``(i) Non-elective inpatient hospital 
                        services.
                            ``(ii) Services in the emergency department 
                        of a hospital.
                            ``(iii) Any of the following services:
                                    ``(I) Extended care services.
                                    ``(II) Services in an acute 
                                rehabilitation facility.
                                    ``(III) Home health services.
            ``(4) Independence at home assessment.--The term 
        `Independence at Home assessment' means, with respect to an 
        eligible beneficiary, a comprehensive medical history, physical 
        examination, and assessment of the beneficiary's clinical and 
        functional status that--
                    ``(A) is conducted by--
                            ``(i) an Independence at Home physician or 
                        an Independence at Home nurse practitioner;
                            ``(ii) a physician assistant, nurse 
                        practitioner, or clinical nurse specialist, as 
                        defined in section 1861(aa)(5), who is employed 
                        by an Independence at Home organization and is 
                        working in collaboration with an Independence 
                        at Home physician or Independence at Home nurse 
                        practitioner; or
                            ``(iii) any other health care professional 
                        that meets such conditions as the Secretary may 
                        specify; and
                    ``(B) includes an assessment of--
                            ``(i) activities of daily living and other 
                        co-morbidities;
                            ``(ii) medications and medication 
                        adherence;
                            ``(iii) affect, cognition, executive 
                        function, and presence of mental disorders;
                            ``(iv) functional status, including 
                        mobility, balance, gait, risk of falling, and 
                        sensory function;
                            ``(v) social functioning and social 
                        integration;
                            ``(vi) environmental needs and a safety 
                        assessment;
                            ``(vii) the ability of the beneficiary's 
                        primary caregiver to assist with the 
                        beneficiary's care as well as the caregiver's 
                        own physical and emotional capacity, education, 
                        and training;
                            ``(viii) whether the beneficiary is likely 
                        to benefit from an Independence at Home 
                        program;
                            ``(ix) whether the conditions in the 
                        beneficiary's home or place of residence would 
                        permit the safe provision of services in the 
                        home or residence, respectively, under an 
                        Independence at Home program; and
                            ``(x) other factors determined appropriate 
                        by the Secretary.
            ``(5) Independence at home care team.--The term 
        `Independence at Home care team'--
                    ``(A) means, with respect to a participant, a team 
                of qualified individuals that provides services to the 
                participant as part of an Independence at Home program; 
                and
                    ``(B) includes an Independence at Home physician or 
                an Independence at Home nurse practitioner and an 
                Independence at Home coordinator (who may also be an 
                Independence at Home physician or an Independence at 
                Home nurse practitioner).
            ``(6) Independence at home coordinator.--The term 
        `Independence at Home coordinator' means, with respect to a 
        participant, an individual who--
                    ``(A) is employed by an Independence at Home 
                organization and is responsible for coordinating all of 
                the elements of the participant's Independence at Home 
                plan;
                    ``(B) is a licensed health professional, such as a 
                physician, registered nurse, nurse practitioner, 
                clinical nurse specialist, physician assistant, or 
                other health care professional as the Secretary 
                determines appropriate, who has at least one year of 
                experience providing and coordinating medical and 
                related services for individuals in their homes; and
                    ``(C) serves as the primary point of contact 
                responsible for communications with the participant and 
                for facilitating communications with other health care 
                providers under the plan.
            ``(7) Independence at home organization.--The term 
        `Independence at Home organization' means a provider of 
        services, a physician or physician group practice, a nurse 
        practitioner or nurse practitioner group practice, or other 
        legal entity which receives payment for services furnished 
        under this title (other than only under this section) and 
        which--
                    ``(A) has entered into an agreement under 
                subsection (a)(2) to provide an Independence at Home 
                program under this section;
                    ``(B)(i) is able to provide all of the elements of 
                the Independence at Home plan in a participant's home 
                or place of residence, or
                    ``(ii) if the organization is not able to provide 
                all such elements in such home or residence, has 
                adequate mechanisms for ensuring the provision of such 
                elements by one or more qualified entities;
                    ``(C) has Independence at Home physicians, clinical 
                nurse specialists, nurse practitioners, or physician 
                assistants available to respond to patient emergencies 
                24 hours a day, seven days a week;
                    ``(D) accepts all eligible beneficiaries from the 
                organization's service area except to the extent that 
                qualified staff are not available; and
                    ``(E) meets other requirements for such an 
                organization under this section.
            ``(8) Independence at home physician.--The term 
        `Independence at Home physician' means a physician who--
                    ``(A) is employed by or affiliated with an 
                Independence at Home organization, as required under 
                paragraph (7)(C), or has another contractual 
                relationship with the Independence at Home organization 
                that requires the physician to be responsible for the 
                plans of care for the physician's patients;
                    ``(B) is certified--
                            ``(i) by the American Board of Family 
                        Physicians, the American Board of Internal 
                        Medicine, the American Osteopathic Board of 
                        Family Physicians, the American Osteopathic 
                        Board of Internal Medicine, the American Board 
                        of Emergency Medicine, or the American Board of 
                        Physical Medicine and Rehabilitation; or
                            ``(ii) by a Board recognized by the 
                        American Board of Medical Specialties and 
                        determined by the Secretary to be appropriate 
                        for the Independence at Home program;
                    ``(C) has--
                            ``(i) a certification in geriatric medicine 
                        as provided by American Board of Medical 
                        Specialties; or
                            ``(ii) passed the clinical competency 
                        examination of the American Academy of Home 
                        Care Physicians and has substantial experience 
                        in the delivery of medical care in the home, 
                        including at least two years of experience in 
                        the management of Medicare patients and one 
                        year of experience in home-based medical care 
                        including at least 200 house calls; and
                    ``(D) has furnished services during the previous 12 
                months for which payment is made under this title.
            ``(9) Independence at home nurse practitioner.--The term 
        `Independence at Home nurse practitioner' means a nurse 
        practitioner who--
                    ``(A) is employed by or affiliated with an 
                Independence at Home organization, as required under 
                paragraph (7)(C), or has another contractual 
                relationship with the Independence at Home organization 
                that requires the nurse practitioner to be responsible 
                for the plans of care for the nurse practitioner's 
                patients;
                    ``(B) practices in accordance with State law 
                regarding scope of practice for nurse practitioners;
                    ``(C) is certified--
                            ``(i) as a Gerontologic Nurse Practitioner 
                        by the American Academy of Nurse Practitioners 
                        Certification Program or the American Nurses 
                        Credentialing Center; or
                            ``(ii) as a family nurse practitioner or 
                        adult nurse practitioner by the American 
                        Academy of Nurse Practitioners Certification 
                        Board or the American Nurses Credentialing 
                        Center and holds a certificate of Added 
                        Qualification in gerontology, elder care or 
                        care of the older adult provided by the 
                        American Academy of Nurse Practitioners, the 
                        American Nurses Credentialing Center or a 
                        national nurse practitioner certification board 
                        deemed by the Secretary to be appropriate for 
                        an Independence at Home program; and
                    ``(D) has furnished services during the previous 12 
                months for which payment is made under this title.
            ``(10) Independence at home plan.--The term `Independence 
        at Home plan' means a plan established under subsection (d)(2) 
        for a specific participant in an Independence at Home program.
            ``(11) Independence at home program.--The term 
        `Independence at Home program' means a program described in 
        subsection (d) that is operated by an Independence at Home 
        organization.
            ``(12) Participant.--The term `participant' means an 
        eligible beneficiary who has voluntarily enrolled in an 
        Independence at Home program.
            ``(13) Qualified entity.--The term `qualified entity' means 
        a person or organization that is licensed or otherwise legally 
        permitted to provide the specific element (or elements) of an 
        Independence at Home plan that the entity has agreed to 
        provide.
            ``(14) Qualifying functional impairment.--The term 
        `qualifying functional impairment' means an inability to 
        perform, without the assistance of another person, two or more 
        activities of daily living.
    ``(c) Identification and Enrollment of Prospective Program 
Participants.--
            ``(1) Notice to eligible independence at home 
        beneficiaries.--The Secretary shall develop a model notice to 
        be made available to Medicare beneficiaries (and to their 
        caregivers) who are potentially eligible for an Independence at 
        Home program by participating providers and by Independence at 
        Home programs. Such notice shall include the following 
        information:
                    ``(A) A description of the potential advantages to 
                the beneficiary participating in an Independence at 
                Home program.
                    ``(B) A description of the eligibility requirements 
                to participate.
                    ``(C) Notice that participation is voluntary.
                    ``(D) A statement that all other Medicare benefits 
                remain available to beneficiaries who enroll in an 
                Independence at Home program.
                    ``(E) Notice that those who enroll in an 
                Independence at Home program may have co-payments for 
                house calls by Independence at Home physicians or by 
                Independence at Home nurse practitioners reduced or 
                eliminated at the discretion of the Independence at 
                Home physician or Independence at Home nurse 
                practitioner involved.
                    ``(F) A description of the services that could 
                potentially be provided under an Independence at Home 
                plan.
                    ``(G) A description of the method for 
                participating, or withdrawing from participation, in an 
                Independence at Home program or becoming no longer 
                eligible to so participate.
            ``(2) Voluntary participation and choice.--An eligible 
        beneficiary may participate in an Independence at Home program 
        through enrollment in such program on a voluntary basis and may 
        terminate such participation at any time. Such a beneficiary 
        may also receive Independence at Home services from the 
        Independence at Home organization of the beneficiary's choice 
        but may not receive Independence at Home services from more 
        than one Independence at Home organization at a time.
    ``(d) Independence at Home Program Requirements.--
            ``(1) In general.--Each Independence at Home program shall, 
        for each participant enrolled in the program--
                    ``(A) designate--
                            ``(i) an Independence at Home physician or 
                        an Independence at Home nurse practitioner; and
                            ``(ii) an Independence at Home coordinator;
                    ``(B) have a process to ensure that the participant 
                received an Independence at Home assessment before 
                enrollment in the program;
                    ``(C) with the participation of the participant (or 
                the participant's representative or caregiver), an 
                Independence at Home physician or an Independence at 
                Home nurse practitioner, and Independence at Home 
                coordinator, develop an Independence at Home plan for 
                the participant in accordance with paragraph (2);
                    ``(D) ensure that the participant receives an 
                Independence at Home assessment at least annually after 
                the original assessment to ensure that the Independence 
                at Home plan for the participant remains current and 
                appropriate;
                    ``(E) implement all of the elements of the 
                participant's Independence at Home plan and in 
                instances in which the Independence at Home 
                organization does not provide specific elements of the 
                Independence at Home plan, ensure that qualified 
                entities successfully implement those specific 
                elements;
                    ``(F) provide for an electronic medical record and 
                electronic health information technology to coordinate 
                the participant's care and to exchange information with 
                the Medicare program and electronic monitoring and 
                communication technologies and mobile diagnostic and 
                therapeutic technologies as appropriate and accepted by 
                the participant; and
                    ``(G) respect the participant's right to health 
                information privacy and obtain permission from the 
                participant (or responsible person) for the use and 
                disclosure of identifiable health information necessary 
                for treatment, payment, or health care operations.
            ``(2) Independence at home plan.--
                    ``(A) In general.--An Independence at Home plan for 
                a participant shall be developed with the participant, 
                an Independence at Home physician or an Independence at 
                Home nurse practitioner, an Independence at Home 
                coordinator, and, if appropriate, one or more of the 
                participant's caregivers and shall--
                            ``(i) document the chronic conditions, co-
                        morbidities, and other health needs identified 
                        in the participant's Independence at Home 
                        assessment;
                            ``(ii) determine which elements of an 
                        Independence at Home plan described in 
                        subparagraph (C) are appropriate for the 
                        participant; and
                            ``(iii) identify the qualified entity 
                        responsible for providing each element of such 
                        plan.
                    ``(B) Communication of individualized independence 
                at home plan to the independence at home coordinator.--
                If the Independence at Home physician or Independence 
                at Home nurse practitioner responsible for conducting 
                the participant's Independence at Home assessment and 
                developing the Independence at Home plan is not the 
                participant's Independence at Home coordinator, the 
                Independence at Home physician or Independence at Home 
                nurse practitioner is responsible for ensuring that the 
                participant's Independence at Home coordinator has such 
                plan and is familiar with the requirements of the plan 
                and has the appropriate contact information for all of 
                the members of the Independence at Home care team.
                    ``(C) Elements of independence at home plan.--An 
                Independence at Home organization shall have the 
                capability to provide, directly or through a qualified 
                entity, and shall offer all of the following elements 
                of an Independence at Home plan to the extent they are 
                appropriate and accepted by a participant:
                            ``(i) Self-care education and preventive 
                        care consistent with the participant's 
                        condition.
                            ``(ii) Coordination of all medical 
                        treatment furnished to the participant, 
                        regardless of whether such treatment is covered 
                        and available to the participant under this 
                        title.
                            ``(iii) Information about, and access to, 
                        hospice care.
                            ``(iv) Pain and palliative care and end-of-
                        life care.
                            ``(v) Education for primary caregivers and 
                        family members.
                            ``(vi) Caregiver counseling services and 
                        information about, and referral to, other 
                        caregiver support and health care services in 
                        the community.
                            ``(vii) Monitoring and management of 
                        medications as well as assistance to 
                        participants and their caregivers with respect 
                        to selection of a prescription drug plan under 
                        part D that best meets the needs of the 
                        participant's chronic conditions.
                            ``(viii) Referral to social services, such 
                        as personal care, meals, volunteers, and 
                        individual and family therapy.
                            ``(ix) Access to phlebotomy and ancillary 
                        laboratory and imaging services, including 
                        point of care laboratory and imaging 
                        diagnostics.
            ``(3) Primary treatment role within an independence at home 
        care team .--An Independence at Home physician or an 
        Independence at Home nurse practitioner may assume the primary 
        treatment role as permitted under State law.
            ``(4) Additional responsibilities.--
                    ``(A) Outcomes report.--Each Independence at Home 
                organization offering an Independence at Home program 
                shall monitor and report to the Secretary, in a manner 
                specified by the Secretary, on--
                            ``(i) patient outcomes;
                            ``(ii) beneficiary, caregiver, and provider 
                        satisfaction with respect to coordination of 
                        the participant's care; and
                            ``(iii) the achievement of mandatory 
                        minimum savings described in subsection (e)(6).
                    ``(B) Additional requirements.--Each such 
                organization and program shall comply with such 
                additional requirements as the Secretary may specify.
    ``(e) Terms and Conditions.--
            ``(1) In general.--An agreement under this section with an 
        Independence at Home organization shall contain such terms and 
        conditions as the Secretary may specify consistent with this 
        section.
            ``(2) Clinical, quality improvement, and financial 
        requirements.--The Secretary may not enter into an agreement 
        with such an organization under this section for the operation 
        of an Independence at Home program unless--
                    ``(A) the program and organization meet the 
                requirements of subsection (d), minimum quality and 
                performance standards developed under paragraph (3), 
                and such clinical, quality improvement, financial, and 
                other requirements as the Secretary deems to be 
                appropriate for participants to be served; and
                    ``(B) the organization demonstrates to the 
                satisfaction of the Secretary that the organization is 
                able to assume financial risk for performance under the 
                agreement with respect to payments made to the 
                organization under such agreement through available 
                reserves, reinsurance, or withholding of funding 
                provided under this title, or such other means as the 
                Secretary determines appropriate.
            ``(3) Minimum quality and performance standards.--
                    ``(A) In general.--The Secretary shall develop 
                mandatory minimum quality and performance standards for 
                Independence at Home organizations and programs.
                    ``(B) Standards to be included.--Such standards 
                shall include measures of--
                            ``(i) participant outcomes;
                            ``(ii) satisfaction of the beneficiary, 
                        caregiver, and provider involved; and
                            ``(iii) cost savings consistent with 
                        paragraph (6).
                    ``(C) Minimum participation standard.--Such 
                standards shall include a requirement that, for any 
                year after the first year, an Independence at Home 
                program had an average number of participants during 
                the previous year of at least 100 participants.
            ``(4) Term of agreement and modification.--The agreement 
        under this subsection shall be, subject to paragraphs (3)(C) 
        and (5), for a period of three years, and the terms and 
        conditions may be modified during the contract period only upon 
        the request of the Independence at Home organization.
            ``(5) Termination and non-renewal of agreement.--
                    ``(A) In general.--If the Secretary determines that 
                an Independence at Home organization has failed to meet 
                the minimum performance standards under paragraph (3) 
                or other requirements under this section, the Secretary 
                may terminate the agreement of the organization at the 
                end of the contract year.
                    ``(B) Required termination where risk to health or 
                safety of a participant.--The Secretary shall terminate 
                an agreement with an Independence at Home organization 
                at any time the Secretary determines that the care 
                being provided by such organization poses a threat to 
                the health and safety of a participant.
                    ``(C) Termination by independence at home 
                organizations.--Notwithstanding any other provision of 
                this subsection, an Independence at Home organization 
                may terminate an agreement with the Secretary under 
                this section to provide an Independence at Home program 
                at the end of a contract year if the organization 
                provides to the Secretary and to the beneficiaries 
                participating in the program notification of such 
                termination more than 90 days before the end of such 
                year. Paragraphs (6), (8), and (9)(B) shall apply to 
                the organization until the date of termination.
                    ``(D) Notice of involuntary termination.--The 
                Secretary shall notify the participants in an 
                Independence at Home program as soon as practicable if 
                a determination is make to terminate an agreement with 
                the Independence at Home organization involuntarily as 
                provided in subparagraphs (A) and (B). Such notice 
                shall inform the beneficiary of any other Independence 
                at Home organizations that might be available to the 
                beneficiary.
            ``(6) Mandatory minimum savings.--
                    ``(A) In general.--Under an agreement under this 
                subsection, each Independence at Home organization 
                shall ensure that during any year of the agreement for 
                its Independence at Home program, there is an aggregate 
                savings in the cost to the program under this title for 
                participating beneficiaries, as calculated under 
                subparagraph (B), that is not less than the product 
                of--
                            ``(i) 5 percent of the estimated average 
                        monthly costs that would have been incurred 
                        under parts A, B, and D if those beneficiaries 
                        had not participated in the Independence at 
                        Home program; and
                            ``(ii) the number of participant-months for 
                        that year.
                    ``(B) Computation of aggregate savings.--
                            ``(i) Model for calculating savings.--The 
                        Secretary shall contract with a nongovernmental 
                        organization or academic institution to 
                        independently develop an analytical model for 
                        determining whether an Independence at Home 
                        program achieves at least savings required 
                        under subparagraph (A) relative to costs that 
                        would have been incurred by Medicare in the 
                        absence of Independence at Home programs. The 
                        analytical model developed by the independent 
                        research organization for making these 
                        determinations shall utilize state-of-the-art 
                        econometric techniques, such as Heckman's 
                        selection correction methodologies, to account 
                        for sample selection bias, omitted variable 
                        bias, or problems with endogeneity.
                            ``(ii) Application of the model.--Using the 
                        model developed under clause (i), the Secretary 
                        shall compare the actual costs to Medicare of 
                        beneficiaries participating in an Independence 
                        at Home program to the predicted costs to 
                        Medicare of such beneficiaries to determine 
                        whether an Independence at Home program 
                        achieves the savings required under 
                        subparagraph (A).
                            ``(iii) Revisions of the model.--The 
                        Secretary shall require that the model 
                        developed under clause (i) for determining 
                        savings shall be designed according to 
                        instructions that will control, or adjust for, 
                        inflation as well as risk factors including, 
                        age, race, gender, disability status, 
                        socioeconomic status, region of country (such 
                        as State, county, metropolitan statistical 
                        area, or zip code), and such other factors as 
                        the Secretary determines to be appropriate, 
                        including adjustment for prior health care 
                        utilization. The Secretary may add to, modify, 
                        or substitute for such adjustment factors if 
                        such changes will improve the sensitivity or 
                        specificity of the calculation of costs 
                        savings.
                            ``(iv) Participant-month.--In making the 
                        calculation described in subparagraph (A), each 
                        month or part of a month in a program year that 
                        a beneficiary participates in an Independence 
                        at Home program shall be counted as a 
                        `participant-month'.
                    ``(C) Notice of savings calculation.--No later than 
                120 days before the beginning of any Independence at 
                Home program year, the Secretary shall publish in the 
                Federal Register a description of the model developed 
                under subparagraph (B)(i) and information for 
                calculating savings required under subparagraph (A), 
                including any revisions, sufficient to permit 
                Independence at Home organizations to determine the 
                savings they will be required to achieve during the 
                program year to meet the savings requirement under such 
                subparagraph. In order to facilitate this notice, the 
                Secretary may designate a single annual date for the 
                beginning of all Independence at Home program years 
                that shall not be later than one year from the date of 
                enactment of this section.
            ``(7) Manner of payment.--Subject to paragraph (8), 
        payments shall be made by the Secretary to an Independence at 
        Home organization at a rate negotiated between the Secretary 
        and the organization under the agreement for--
                    ``(A) Independence at Home assessments; and
                    ``(B) on a per-participant, per-month basis for the 
                items and services required to be provided or made 
                available under subsection (d).
            ``(8) Ensuring mandatory minimum savings.--The Secretary 
        shall require any Independence at Home organization that fails 
        in any year to achieve the mandatory minimum savings described 
        in paragraph (6) to provide those savings by refunding payments 
        made to the organization under paragraph (7) during such year.
            ``(9) Budget neutral payment condition.--
                    ``(A) In general.--Under this section, the 
                Secretary shall ensure that the cumulative, aggregate 
                sum of Medicare program benefit expenditures under 
                parts A, B, and D for participants in Independence at 
                Home programs and funds paid to Independence at Home 
                organizations under this section, shall not exceed the 
                Medicare program benefit expenditures under such parts 
                that the Secretary estimates would have been made for 
                such participants in the absence of such programs.
                    ``(B) Treatment of savings.--If an Independence at 
                Home organization achieves aggregate savings in a year 
                in excess of the mandatory minimum savings described in 
                paragraph (6), 80 percent of such aggregate savings 
                shall be paid to the organization and the remainder 
                shall be retained by the programs under this title.
    ``(f) Waiver of Coinsurance for House Calls.--A physician or nurse 
practitioner furnishing services in the home or residence of a 
participant in an Independence at Home program may waive collection of 
any coinsurance that might otherwise be payable under section 1833(a) 
with respect to such services.
    ``(g) Report.--Not later than one year after the end of the 
Independence at Home demonstration project under this section, the 
Secretary shall submit to Congress a report on such project. Such 
report shall include information on--
            ``(1) whether Independence at Home programs under the 
        project met the performance standards for beneficiary, 
        caregiver, and provider satisfaction; and
            ``(2) participant outcomes and cost savings, as well as the 
        characteristics of the programs that were most effective and 
        whether the participant eligibility criteria identified 
        beneficiaries who were in the top ten percent of the highest 
        cost Medicare beneficiaries.''.
    (b) Conforming Amendments.--
            (1) Section 1833(a) of such Act (42 U.S.C. 1395l(a)) is 
        amended, in the matter before paragraph (1), by inserting ``and 
        section 1807A(f)'' after ``section 1876''.
            (2) Section 1128B(b)(3) of such Act (42 U.S.C. 1320a-
        7b(b)(3)) is amended--
                    (A) by striking ``and'' at the end of subparagraph 
                (G);
                    (B) by striking ``1853(a)(4).'' at the end of the 
                first subparagraph (H) and inserting ``1853(a)(4);'';
                    (C) by redesignating the second subparagraph (H) as 
                subparagraph (I) and by striking the period at the end 
                and inserting ``; and''; and
                    (D) by adding at the end the following new 
                subparagraph:
                    ``(J) a waiver of coinsurance under section 
                1807A(f).''.
                                 <all>