[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 1131 Introduced in Senate (IS)]

111th CONGRESS
  1st Session
                                S. 1131

To amend title XVIII of the Social Security Act to provide certain high 
cost Medicare beneficiaries suffering from multiple chronic conditions 
with access to coordinated, primary care medical services in lower cost 
  treatment settings, such as their residences, under a plan of care 
     developed by a team of qualified and experienced health care 
                             professionals.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                              May 21, 2009

   Mr. Wyden (for himself, Mr. Burr, Mr. Whitehouse, and Mr. Cardin) 
introduced the following bill; which was read twice and referred to the 
                          Committee on Finance

_______________________________________________________________________

                                 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 coordinated, primary care medical services in lower cost 
  treatment settings, such as their residences, under a plan of care 
     developed by a team of qualified and experienced health care 
                             professionals.

    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 2009''.

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) 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.
            (5) The Independence at Home Act creates a chronic care 
        coordination pilot project to bring primary care medical 
        services to the highest cost Medicare beneficiaries with 
        multiple chronic conditions in their home or place of residence 
        so that they may be as independent as possible for as long as 
        possible in a comfortable setting.
            (6) The Independence at Home Act generates savings by 
        providing better, more coordinated care across all treatment 
        settings to the highest cost Medicare beneficiaries with 
        multiple chronic conditions, reducing duplicative and 
        unnecessary services, and avoiding unnecessary 
        hospitalizations, nursing home admissions, and emergency room 
        visits.
            (7) The Independence at Home Act holds providers 
        accountable for improving beneficiary outcomes, ensuring 
        patient and caregiver satisfaction, and achieving cost savings 
        to Medicare on an annual basis.
            (8) The Independence at Home Act creates 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 Act contains the central 
        elements of proven home-based primary care delivery models that 
        have been utilized for years by the Department of Veterans 
        Affairs and ``house calls'' programs across the country to 
        deliver coordinated care for chronic conditions in the comfort 
        of a patient's home or place of residence.

SEC. 3. ESTABLISHMENT OF VOLUNTARY INDEPENDENCE AT HOME CHRONIC CARE 
              COORDINATION PILOT 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 Pilot 
Project.--A pilot 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 pilot project

    ``Sec. 1807A.  (a) Implementation.--
            ``(1) In general.--The Secretary shall provide for the 
        phased in development, implementation, and evaluation of 
        Independence at Home programs described in this section to meet 
        the following objectives:
                    ``(A) To improve patient outcomes, compared to 
                comparable beneficiaries who do not participate in such 
                a program, through reduced hospitalizations, nursing 
                home admissions, or emergency room visits, increased 
                symptom self-management, and similar results.
                    ``(B) To improve satisfaction of patients and 
                caregivers, as demonstrated through a quantitative pre-
                test and post-test survey developed by the Secretary 
                that measures patient and caregiver satisfaction of 
                care coordination, educational information, timeliness 
                of response, and similar care features.
                    ``(C) To achieve a minimum of 5 percent cost 
                savings in the care of beneficiaries under this title 
                suffering from multiple high cost chronic diseases.
            ``(2) Initial implementation (phase i).--
                    ``(A) In general.--In carrying out this section and 
                to the extent possible, the Secretary shall enter into 
                agreements with at least two unaffiliated Independence 
                at Home organizations in each of the 13 highest cost 
                States (based on average per capita expenditures per 
                State under this title), in the District of Columbia, 
                and in 13 additional States that are representative of 
                other regions of the United States and include 
                medically underserved rural and urban areas, to provide 
                chronic care coordination services for a period of 
                three years or until those agreements are terminated by 
                the Secretary. Such agreements under this paragraph 
                shall continue in effect until the Secretary makes the 
                determination described in paragraph (3) or until those 
                agreements are supplanted by new agreements under such 
                paragraph. The phase of implementation under this 
                paragraph is referred to in this section as the 
                `initial implementation' phase or `phase I'.
                    ``(B) Preference.--In selecting Independence at 
                Home organizations under this paragraph, the Secretary 
                shall give a preference, to the extent practicable, to 
                organizations that--
                            ``(i) have documented experience in 
                        furnishing the types of services covered by 
                        this section to eligible beneficiaries in the 
                        home or place of residence using qualified 
                        teams of health care professionals that are 
                        directed by individuals who have the 
                        qualifications of Independence at Home 
                        physicians, or in cases when such direction is 
                        provided by an Independence at Home physician 
                        to a physician assistant who has at least one 
                        year of experience providing gerontological 
                        medical and related services for chronically 
                        ill individuals in their homes, or other 
                        similar qualification as determined by the 
                        Secretary to be appropriate for the 
                        Independence at Home program, by the physician 
                        assistant acting under the supervision of an 
                        Independence at Home physician and as permitted 
                        under State law, or Independence at Home nurse 
                        practitioners;
                            ``(ii) have the capacity to provide 
                        services covered by this section to at least 
                        150 eligible beneficiaries; and
                            ``(iii) use electronic medical records, 
                        health information technology, and 
                        individualized plans of care.
            ``(3) Expanded implementation phase (phase ii).--
                    ``(A) In general.--For periods beginning after the 
                end of the 3-year initial implementation period under 
                paragraph (2), subject to subparagraph (B), the 
                Secretary shall renew agreements described in paragraph 
                (2) with Independence at Home organization that have 
                met all 3 objectives specified in paragraph (1) and 
                enter into agreements described in paragraph (2) with 
                any other organization that is located in any State or 
                the District of Columbia, that was not an Independence 
                at Home organization during the initial implementation 
                period, and that meets the qualifications of an 
                Independence at Home organization under this section. 
                The Secretary may terminate and not renew such an 
                agreement with an organization that has not met such 
                objectives during the initial implementation period. 
                The phase of implementation under this paragraph is 
                referred to in this section as the `expanded 
                implementation' phase or `phase II'.
                    ``(B) Contingency.--The expanded implementation 
                under subparagraph (A) shall not occur if the Secretary 
                finds, not later than 60 days after the date of 
                issuance of the independent evaluation under paragraph 
                (5), that continuation of the Independence at Home 
                project is not in the best interest of beneficiaries 
                under this title or in the best interest of Federal 
                health care programs.
            ``(4) Eligibility.--No organization shall be prohibited 
        from participating under this section during expanded 
        implementation phase under paragraph (3) (and, to the extent 
        practicable, during initial implementation phase under 
        paragraph (2)) because of its small size as long as it meets 
        the eligibility requirements of this section.
            ``(5) Independent evaluations.--
                    ``(A) In general.--The Secretary shall contract for 
                an independent evaluation of the initial implementation 
                phase under paragraph (2) with an interim report to 
                Congress to be provided on such evaluation as soon as 
                practicable after the first year of such phase and a 
                final report to be provided to Congress as soon as 
                practicable following the conclusion of the initial 
                implementation phase, but not later than 6 months 
                following the end of such phase. Such an evaluation 
                shall be conducted by individuals with knowledge of 
                chronic care coordination programs for the targeted 
                patient population and demonstrated experience in the 
                evaluation of such programs.
                    ``(B) Information to be included.--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 in producing improvements in--
                            ``(i) beneficiary, caregiver, and provider 
                        satisfaction;
                            ``(ii) health outcomes appropriate for 
                        patients with multiple chronic diseases; and
                            ``(iii) cost savings to the program under 
                        this title, such as in reducing--
                                    ``(I) hospital and skilled nursing 
                                facility admission rates and lengths of 
                                stay;
                                    ``(II) hospital readmission rates; 
                                and
                                    ``(III) emergency department 
                                visits.
                    ``(C) Breakdown by condition.--Each such report 
                shall include data on performance of Independence at 
                Home organizations in responding to the needs of 
                eligible beneficiaries with specific chronic conditions 
                and combinations of conditions, as well as the overall 
                eligible beneficiary population.
            ``(6) Agreements.--
                    ``(A) In general.--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.
                    ``(B) Authority.--If the Secretary deems it 
                necessary to serve the best interest of the 
                beneficiaries under this title or the best interest of 
                Federal health care programs, the Secretary may--
                            ``(i) require screening of all potential 
                        Independence at Home organizations, including 
                        owners (such as through fingerprinting, 
                        licensure checks, site-visits, and other 
                        database checks), before entering into an 
                        agreement;
                            ``(ii) require a provisional period during 
                        which a new Independence at Home organization 
                        would be subject to enhanced oversight (such as 
                        prepayment review, unannounced site visits, and 
                        payment caps); and
                            ``(iii) require applicants to disclose 
                        previous affiliation with entities that have 
                        uncollected Medicare or Medicaid debt, and 
                        authorize the denial of enrollment if the 
                        Secretary determines that these affiliations 
                        pose undue risk to the program.
            ``(7) 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. Such specifications shall describe 
        the implementation process from initial to final implementation 
        phases, including how the Secretary will identify and notify 
        potential enrollees and how and when beneficiaries may enroll 
        and disenroll from Independence at Home programs and change the 
        programs in which they are enrolled.
            ``(8) 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.
            ``(9) Annual best practices conference.--During the initial 
        implementation phase and to the extent practicable at intervals 
        thereafter, the Secretary shall provide for an annual 
        Independence at Home teleconference for Independence at Home 
        organizations to share best practices and review treatment 
        interventions and protocols that were successful in meeting all 
        3 objectives specified in paragraph (1).
    ``(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 part A for the 
                        following services:
                                    ``(I) Non-elective inpatient 
                                hospital services.
                                    ``(II) Services in the emergency 
                                department of a hospital.
                                    ``(III) Any one of the following:
                                            ``(aa) Skilled nursing or 
                                        sub-acute rehabilitation 
                                        services in a Medicare-
                                        certified nursing facility.
                                            ``(bb) Comprehensive acute 
                                        rehabilitation facility or 
                                        Comprehensive outpatient 
                                        rehabilitation facility 
                                        services.
                                            ``(cc) Skilled nursing or 
                                        rehabilitation services through 
                                        a Medicare-certified home 
                                        health agency.
                    ``(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 a 12-month period 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.
            ``(4) Independence at home assessment.--The term 
        `Independence at Home assessment' means a determination of 
        eligibility of an individual for an Independence at Home 
        program as an eligible beneficiary (as defined in paragraph 
        (3)), a comprehensive medical history, physical examination, 
        and assessment of the beneficiary's clinical and functional 
        status that--
                    ``(A) is conducted in person by an individual--
                            ``(i) who--
                                    ``(I) is an Independence at Home 
                                physician or an Independence at Home 
                                nurse practitioner; or
                                    ``(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 supervised by an Independence at 
                                Home physician or Independence at Home 
                                nurse practitioner; and
                            ``(ii) does not have an ownership interest 
                        in the Independence at Home organization unless 
                        the Secretary determines that it is 
                        impracticable to preclude such individual's 
                        involvement; 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, in the professional 
                        judgment of the individual conducting the 
                        assessment, 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;
                            ``(x) whether the beneficiary has a 
                        designated primary care physician whom the 
                        beneficiary has seen in an office-based setting 
                        within the previous 12 months; and
                            ``(xi) 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 services 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 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) provides all of the services 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 services in such home or residence, has 
                adequate mechanisms for ensuring the provision of such 
                services 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, as determined under the 
                agreement with the Secretary under this section, 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 make in-home visits and 
                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 make in-home 
                visits and 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 service (or services) 
        provided under 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.
            ``(15) Qualified individual.--The term `qualified 
        individual' means a individual that is licensed or otherwise 
        legally permitted to provide the specific service (or services) 
        under an Independence at Home plan that the individual has 
        agreed to provide.
    ``(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 will be responsible for 
                copayments for house calls made by Independence at Home 
                physicians, physician assistants, or by Independence at 
                Home nurse practitioners, except that such copayments 
                may be reduced or eliminated at the discretion of the 
                Independence at Home physician, physician assistant, or 
                Independence at Home nurse practitioner involved in 
                accordance with subsection (f).
                    ``(F) A description of the services that could be 
                provided.
                    ``(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, a physician assistant 
                under the supervision of an Independence at Home 
                physician and as permitted under State law, or an 
                Independence at Home nurse practitioner, and the 
                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 every 6 months 
                after the original assessment to ensure that the 
                Independence at Home plan for the participant remains 
                current and appropriate;
                    ``(E) implement all of the services under the 
                participant's Independence at Home plan and in 
                instances in which the Independence at Home 
                organization does not provide specific services within 
                the Independence at Home plan, ensure that qualified 
                entities successfully provide those specific services; 
                and
                    ``(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.
            ``(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, a physician 
                assistant under the supervision of an Independence at 
                Home physician and as permitted under State law, an 
                Independence at Home nurse practitioner, or 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 services under an 
                        Independence at Home plan described in 
                        subparagraph (C) are appropriate for the 
                        participant; and
                            ``(iii) identify the qualified entity 
                        responsible for providing each service under 
                        such plan.
                    ``(B) Communication of individualized independence 
                at home plan to the independence at home coordinator.--
                If the individual 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) Services provided under an independence at 
                home plan.--An Independence at Home organization shall 
                coordinate and make available through referral to a 
                qualified entity the services described in the 
                following clauses (i) through (iii) to the extent they 
                are needed and covered by under this title and shall 
                provide the care coordination services described in the 
                following clause (iv) to the extent they are 
                appropriate and accepted by a participant:
                            ``(i) Primary care services, such as 
                        physician visits, diagnosis, treatment, and 
                        preventive services.
                            ``(ii) Home health services, such as 
                        skilled nursing care and physical and 
                        occupational therapy.
                            ``(iii) Phlebotomy and ancillary laboratory 
                        and imaging services, including point of care 
                        laboratory and imaging diagnostics.
                            ``(iv) Care coordination services, 
                        consisting of--
                                    ``(I) Monitoring and management of 
                                medications by a pharmacist who is 
                                certified in geriatric pharmacy by the 
                                Commission for Certification in 
                                Geriatric Pharmacy or possesses other 
                                comparable certification demonstrating 
                                knowledge and expertise in geriatric 
                                pharmacotherapy, 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.
                                    ``(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) Self-care education and 
                                preventive care consistent with the 
                                participant's condition.
                                    ``(IV) Education for primary 
                                caregivers and family members.
                                    ``(V) Caregiver counseling services 
                                and information about, and referral to, 
                                other caregiver support and health care 
                                services in the community.
                                    ``(VI) Referral to social services, 
                                such as personal care, meals, 
                                volunteers, and individual and family 
                                therapy.
                                    ``(VII) Information about, and 
                                access to, hospice care.
                                    ``(VIII) Pain and palliative care 
                                and end-of-life care, including 
                                information about developing advanced 
                                directives and physicians orders for 
                                life sustaining treatment.
            ``(3) Primary treatment role within an independence at home 
        care team.--An Independence at Home physician, a physician 
        assistant under the supervision of an Independence at Home 
        physician and as permitted under State law, 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 provide the Secretary 
                with listings of individuals employed by the 
                organization, including contract employees, and 
                individuals with an ownership interest in the 
                organization and 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, 
                program integrity, 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) improvement in participant outcomes;
                            ``(ii) improvement in 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 and except as the Secretary 
                may provide for a program serving a rural area, 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 by the 
        Secretary as necessary to serve the best interest of the 
        beneficiaries under this title or the best interest of Federal 
        health care programs or 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, or if the 
                Secretary deems it necessary to serve the best interest 
                of the beneficiaries under this title or the best 
                interest of Federal health care programs, 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 made 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) Required.--
                            ``(i) 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 5 
                        percent of the product described in clause (ii) 
                        for such participating beneficiaries and year.
                            ``(ii) Product described.--The product 
                        described in this clause for participating 
                        beneficiaries in an Independence at Home 
                        program for a year is the product of--
                                    ``(I) the estimated average monthly 
                                costs that would have been incurred 
                                under parts A and B (and, to the extent 
                                cost information is available, part 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 
                30 days before the beginning of the first year of the 
                pilot project under this section and 120 days before 
                the beginning of any Independence at Home program year 
                after the first such 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 
                subparagraph (A). 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)(2)(C)(iv).
            ``(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.--
                            ``(i) Initial implementation phase.--If an 
                        Independence at Home organization achieves 
                        aggregate savings in a year in the initial 
                        implementation phase in excess of the mandatory 
                        minimum savings described in paragraph 
                        (6)(A)(ii), 80 percent of such aggregate 
                        savings shall be paid to the organization and 
                        the remainder shall be retained by the programs 
                        under this title during the initial 
                        implementation phase.
                            ``(ii) Expanded implementation phase.--If 
                        an Independence at Home organization achieves 
                        aggregate savings in a year in the expanded 
                        implementation phase in excess of 5 percent of 
                        the product described in paragraph (6)(A)(ii)--
                                    ``(I) insofar as such savings do 
                                not exceed 25 percent of such product, 
                                80 percent of such aggregate savings 
                                shall be paid to the organization and 
                                the remainder shall be retained by the 
                                programs under this title; and
                                    ``(II) insofar as such savings 
                                exceed 25 percent of such product, in 
                                the Secretary's discretion, 50 percent 
                                of such excess 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, 
physician assistant, or nurse practitioner furnishing services related 
to the Independence at Home program 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 but only if the conditions described in 
section 1128A(i)(6)(A) are met.
    ``(g) Report.--Not later than three months after the date of 
receipt of the independent evaluation provided under subsection (a)(5) 
and each year thereafter during which this section is being 
implemented, the Secretary shall submit to the Committees of 
jurisdiction in Congress a report that shall include--
            ``(1) whether the Independence at Home programs under this 
        section are meeting the minimum quality and performance 
        standards in (e)(3);
            ``(2) a comparative evaluation of Independence at Home 
        organizations in order to identify which programs, and 
        characteristics of those programs, were the most effective in 
        producing the best participant outcomes, patient and caregiver 
        satisfaction, and cost savings; and
            ``(3) an evaluation of whether the participant eligibility 
        criteria identified beneficiaries who were in the top ten 
        percent of the highest cost Medicare beneficiaries.''.
    (b) Conforming Amendment.--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''.
                                 <all>