[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 1202 Introduced in Senate (IS)]

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116th CONGRESS
  1st Session
                                S. 1202

   To amend title XVIII of the Social Security Act to provide for a 
   permanent Independence at Home medical practice program under the 
                           Medicare program.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             April 11, 2019

Mr. Markey (for himself and Mr. Portman) 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 for a 
   permanent Independence at Home medical practice program under the 
                           Medicare program.

    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 2019''.

SEC. 2. INDEPENDENCE AT HOME MEDICAL PRACTICE PROGRAM.

    (a) Program.--Title XVIII of the Social Security Act is amended by 
inserting after section 1866F the following new section:

            ``independence at home medical practice program

    ``Sec. 1866G.  (a) Establishment.--
            ``(1) In general.--Not later than January 1, 2021, the 
        Secretary shall establish and implement a national independence 
        at home medical practice program (in this section referred to 
        as the `Program') that utilizes primary care teams that--
                    ``(A) are directed by physicians, nurse 
                practitioners, or physician assistants; and
                    ``(B) emphasize home-based care that is designed to 
                reduce expenditures and improve health outcomes in the 
                provision of items and services under this title to 
                applicable beneficiaries.
            ``(2) Goals.--Under the Program, an independence at home 
        medical practice shall be accountable for providing 
        comprehensive, coordinated, continuous, and accessible care to 
        applicable beneficiaries at home and coordinating health care 
        across all treatment settings, resulting in--
                    ``(A) reducing preventable hospitalizations;
                    ``(B) preventing hospital readmissions;
                    ``(C) reducing emergency room visits;
                    ``(D) improving health outcomes commensurate with 
                each applicable beneficiary's stage of chronic illness;
                    ``(E) improving the efficiency of care, such as by 
                reducing duplicative diagnostic and laboratory tests;
                    ``(F) reducing the cost of items and services 
                covered under this title; and
                    ``(G) achieving applicable beneficiary and family 
                caregiver satisfaction.
    ``(b) Independence at Home Medical Practice.--
            ``(1) Independence at home medical practice defined.--In 
        this section:
                    ``(A) In general.--The term `independence at home 
                medical practice' means a legal entity that meets each 
                of the following requirements:
                            ``(i) The entity is comprised of an 
                        individual physician, nurse practitioner, or 
                        physician assistant or group of such 
                        practitioners that furnishes care as part of a 
                        team that may include physicians, nurse 
                        practitioners, nurses, physician assistants, 
                        pharmacists, licensed mental health 
                        practitioners, social workers, and other health 
                        and social services staff, as appropriate.
                            ``(ii) The entity is organized, at least in 
                        part, for the purpose of furnishing physicians' 
                        services.
                            ``(iii) The entity--
                                    ``(I) has experience in furnishing 
                                home-based primary care services to 
                                applicable beneficiaries, as determined 
                                appropriate by the Secretary;
                                    ``(II) makes in-home visits; and
                                    ``(III) is available 24 hours per 
                                day, seven days per week, to carry out 
                                plans of care that are tailored to an 
                                applicable beneficiary's chronic 
                                conditions and designed to achieve the 
                                goals described in subparagraphs (A) 
                                through (G) of subsection (a)(2).
                            ``(iv) The entity enters into an agreement 
                        with the Secretary.
                            ``(v) The entity furnishes services to at 
                        least 200 applicable beneficiaries during each 
                        year covered under the agreement unless the 
                        Secretary determines that a lower minimum 
                        number of applicable beneficiaries is necessary 
                        for the goals of the Program to be achieved.
                            ``(vi) The entity uses certified electronic 
                        health record technology and may use remote 
                        monitoring, mobile diagnostic technology, 
                        telehealth, and other communications-based 
                        technology services, as determined appropriate 
                        by the Secretary.
                            ``(vii) The entity meets such other 
                        criteria as the Secretary determines to be 
                        appropriate to participate in the Program.
                    ``(B) Physician.--The term `physician' means a 
                physician described in section 1861(r)(1) who has the 
                medical training or experience to fulfill the 
                physician's role described in subparagraph (A)(i).
            ``(2) Inclusion of affiliated providers and 
        practitioners.--Nothing in this subsection shall prevent an 
        independence at home medical practice from including providers 
        of services, practitioners described in section 1842(b)(18)(C), 
        or other practitioners, including pharmacists, in an 
        arrangement with the practice to share in any savings under the 
        Program.
    ``(c) Quality Measures and Performance Standards.--
            ``(1) Quality measures.--
                    ``(A) In general.--The Secretary shall solicit 
                stakeholder input and, taking into consideration such 
                input, determine appropriate quality measures to assess 
                the quality of care furnished by independence at home 
                medical practices. To the extent possible, such 
                measures shall include outcome measures and experience 
                of care measures.
                    ``(B) Reporting requirements.--Under the Program, 
                an independence at home medical practice shall submit 
                data in a form and manner and at a frequency specified 
                by the Secretary.
            ``(2) Quality performance standards.--The Secretary shall 
        establish quality performance standards that independence at 
        home medical practices must meet in order to be eligible to 
        receive incentive payments under subsection (d)(2).
            ``(3) Data sharing.--Not less frequently than on a 
        quarterly basis, the Secretary shall provide independence at 
        home medical practices with regular practice-level feedback 
        reports on cost and utilization data in a clear and actionable 
        manner. These reports shall include, to the extent practicable, 
        information on fee-for-service cost and utilization, as well as 
        beneficiary-level lists of emergency department visits, 
        hospitalizations, hierarchical condition category risk scores, 
        quality performance data, claims line feed, and other high-cost 
        services used in the previous quarter, together with other data 
        that may be useful for practices, as determined by the 
        Secretary.
    ``(d) Incentive Payment Methodology.--
            ``(1) Establishment of target spending level.--The 
        Secretary shall establish an estimated annual spending target 
        based on the amount the Secretary estimates would have been 
        spent in the absence of the Program, for items and services 
        covered under parts A and B furnished to applicable 
        beneficiaries or comparable beneficiaries, as determined by the 
        Secretary, for each independence at home medical practice under 
        this section. Such spending targets shall be determined on a 
        per capita basis. Such spending targets shall include a risk 
        corridor that takes into account normal variation in 
        expenditures for items and services covered under parts A and B 
        furnished to such beneficiaries with the size of the corridor 
        being related to the number of applicable beneficiaries 
        furnished services by each independence at home medical 
        practice. The spending targets may also be adjusted for 
        applicable beneficiary risk characteristics, factors relevant 
        to characterize random variation among practices, and other 
        factors as the Secretary determines appropriate.
            ``(2) Incentive payments.--Subject to meeting the quality 
        performance standards under subsection (c)(2), an independence 
        at home medical practice is eligible to receive an incentive 
        payment under the Program if actual expenditures for a year for 
        the applicable beneficiaries who are attributed to the practice 
        are less than the estimated spending target established under 
        paragraph (1) for such year. An incentive payment for such year 
        shall be equal to a portion (as determined by the Secretary but 
        in no case greater than 80 percent) of the amount by which 
        actual expenditures (including incentive payments under this 
        paragraph) for applicable beneficiaries under parts A and B for 
        such year are estimated to be less than 5 percent less than the 
        estimated spending target for such year, as determined under 
        paragraph (1).
    ``(e) Applicable Beneficiary.--
            ``(1) In general.--In this section, the term `applicable 
        beneficiary', with respect to an independence at home medical 
        practice, is an individual who is attributed to such practice 
        as a newly-assigned beneficiary or a continuously-assigned 
        beneficiary (as such terms are defined in paragraphs (2) and 
        (3), respectively).
            ``(2) Newly-assigned beneficiary defined.--For purposes of 
        paragraph (1), the term `newly-assigned beneficiary' means an 
        individual whom the independence at home medical practice has 
        determined--
                    ``(A) is entitled to benefits under part A and 
                enrolled for benefits under part B;
                    ``(B) is not--
                            ``(i) enrolled in a Medicare Advantage plan 
                        under part C or a PACE program under section 
                        1894;
                            ``(ii) attributed under--
                                    ``(I) another shared savings 
                                program, under this title, such as 
                                under section 1899; or
                                    ``(II) a model tested or expanded 
                                under section 1115A that involves 
                                shared savings under this title, or any 
                                other demonstration that involves such 
                                shared savings; or
                            ``(iii) determined to have end stage renal 
                        disease as provided in section 226A or 
                        receiving dialysis at home;
                    ``(C) has two or more chronic illnesses, as 
                determined by the Secretary, such as congestive heart 
                failure, diabetes, chronic obstructive pulmonary 
                disease, ischemic heart disease, stroke, Alzheimer's 
                Disease and neurodegenerative diseases, other dementias 
                designated by the Secretary, and other diseases and 
                conditions which result in high costs under this title;
                    ``(D) subject to paragraph (4), during the 12-month 
                period immediately preceding the individual's 
                attribution to an independence at home medical 
                practice--
                            ``(i) had a nonelective hospital admission; 
                        and
                            ``(ii) received--
                                    ``(I) skilled nursing care or 
                                rehabilitation services in a skilled 
                                nursing facility paid under section 
                                1888(e);
                                    ``(II) rehabilitation services in 
                                an inpatient rehabilitation facility; 
                                or
                                    ``(III) part-time or intermittent 
                                nursing care (as described in section 
                                1861(m)(1)) through a home health 
                                agency or physical or occupational 
                                therapy or speech-language pathology 
                                services (as described in section 
                                1861(m)(2)) through a home health 
                                agency;
                    ``(E) has not been assigned to an independence at 
                home medical practice in a previous participation year 
                during an agreement period; and
                    ``(F) meets such other criteria as the Secretary 
                determines appropriate.
            ``(3) Continuously-assigned beneficiary defined.--For 
        purposes of paragraph (1), the term `continuously-assigned 
        beneficiary' means an individual whom the independence at home 
        medical practice has determined--
                    ``(A) meets the criteria described in subparagraphs 
                (A) through (C) and subparagraph (F) of paragraph (2); 
                and
                    ``(B) has two or more functional dependencies 
                requiring the assistance of another person (such as 
                bathing, dressing, toileting, walking, or feeding).
            ``(4) Waiver of certain requirements when beneficiary 
        changes plans.--The requirements under paragraph (2)(D) shall 
        not apply when an individual is attributed to an independence 
        at home medical practice under this section subsequent to the 
        first time an individual is attributed to such a practice under 
        this section.
            ``(5) Patient election to participate.--The Secretary shall 
        adopt an appropriate method to determine that applicable 
        beneficiaries have agreed to enroll in an independence at home 
        medical practice. Enrollment in an independence at home medical 
        practice shall be voluntary.
            ``(6) Beneficiary access to services.--Nothing in this 
        section shall be construed as--
                    ``(A) encouraging physicians, nurse practitioners, 
                physician assistants, or other team members to limit 
                applicable beneficiary access to services covered under 
                this title; or
                    ``(B) requiring applicable beneficiaries to 
                relinquish access to any benefit under this title as a 
                condition of receiving services from an independence at 
                home medical practice.
    ``(f) Agreements.--
            ``(1) In general.--Subject to paragraph (2), an agreement 
        with an independence at home medical practice under the Program 
        shall be for a period determined appropriate by the Secretary 
        but in no case less than 3 years.
            ``(2) Renewals.--Subject to subsection (j), the Secretary 
        may renew an agreement with an independence at home medical 
        practice under the Program.
    ``(g) Permitting Practices To Furnish Supplemental Benefits at Own 
Expense.--Under the Program, independence at home medical practices may 
furnish applicable beneficiaries with items and services for which 
payment is not made under parts A and B, as determined by the 
Secretary. No payment for such items and services shall be made under 
this title.
    ``(h) Waiver Authority.--
            ``(1) In general.--Subject to paragraph (2), the Secretary 
        may waive such provisions of this title and title XI as the 
        Secretary determines necessary in order to implement the 
        Program.
            ``(2) Limitation.--The Secretary may only waive the 
        collection of coinsurance that is payable by individuals under 
        section 1833(a)(1) if the Chief Actuary of the Centers for 
        Medicare & Medicaid Services certifies that such a waiver would 
        reduce (or would not result in any increase in) net program 
        spending under this title.
    ``(i) Administration.--Chapter 35 of title 44, United States Code, 
shall not apply to this section.
    ``(j) Termination and Re-Entry.--
            ``(1) Mandatory termination.--The Secretary shall terminate 
        an agreement with an independence at home medical practice if--
                    ``(A) the Secretary determines that the practice 
                did not achieve savings for the third of 3 consecutive 
                years under the Program; or
                    ``(B) such practice fails to meet at least a 
                minimum number of quality performance standards 
                established under subsection (c)(2) during any year of 
                the agreement period.
            ``(2) Permissive termination.--The Secretary may terminate 
        an agreement with an independence at home medical practice for 
        such other reasons determined appropriate by the Secretary.
            ``(3) Re-entry.--In the case where an independence at home 
        medical practice voluntarily elects to exit the Program during 
        the demonstration phase under section 1866E or the transition 
        under subsection (k)(1), the Secretary may re-enter into an 
        agreement with such practice under this section if the 
        Secretary determines that the practice would have otherwise met 
        the requirements to remain in the Program under this section.
    ``(k) Practice Transitions.--
            ``(1) Practice making transition from demonstration.--The 
        Secretary shall provide for an appropriate transition from the 
        demonstration program under section 1866E to the Program under 
        this section. Such transition shall include a process that 
        ensures that independence at home medical practices and 
        applicable beneficiaries participating in such demonstration 
        are automatically included in the Program under this section at 
        the time of the implementation of the Program.
            ``(2) Practices newly enrolling in the program.--The 
        Secretary shall also provide for the participation of new 
        medical practices in the Program under this section, defined as 
        practices that have not participated in the demonstration 
        program under section 1866E previously, as well as practices 
        with previous experience participating in such demonstration 
        program but who may not be participating at the time of the 
        implementation of the Program under this section.
            ``(3) Special rule for individuals participating in similar 
        programs.--In the case of an individual who has regularly 
        received home-based primary care services, as determined by the 
        Secretary, during the 12-month period immediately preceding the 
        individual's attribution to an independence at home medical 
        practice for the first time, the Secretary may, as determined 
        appropriate, apply clause (i) of subsection (e)(2)(D) (relating 
        to a prior nonelective hospital admission) by increasing the 
        12-month period described in such subsection as it relates to 
        such clause to a period of up to 24 months.
    ``(l) Limitation on Review.--There shall be no administrative or 
judicial review under section 1869, section 1878, or otherwise of--
            ``(1) the attribution of applicable beneficiaries to an 
        independence at home medical practice;
            ``(2) the determination of the estimated annual spending 
        target for an independence at home medical practice under 
        subsection (d)(1);
            ``(3) the assessment of the quality of care furnished by an 
        independence at home medical practice and the establishment of 
        quality performance standards under subsection (c);
            ``(4) the determination of whether an independence at home 
        medical practice is eligible for incentive payments under 
        subsection (d)(2), and the amount of such incentive payments; 
        and
            ``(5) the termination of an independence at home medical 
        practice under subsection (j).''.
    (b) GAO Study and Report.--
            (1) Study.--The Comptroller General of the United States 
        shall conduct a study on the independence at home medical 
        practice program under section 1866G of the Social Security 
        Act, as added by subsection (a). Such study shall include an 
        analysis of--
                    (A) whether independence at home medical practices 
                are meeting the requirements under such program;
                    (B) whether such program is reducing expenditures 
                under this title;
                    (C) the care that beneficiaries are receiving under 
                such program; and
                    (D) other areas determined appropriate by the 
                Comptroller General.
            (2) Report.--Not later than 5 years after the date of the 
        implementation of such independence at home medical practice 
        program, the Comptroller General of the United States shall 
        submit to Congress a report on the study conducted under 
        paragraph (1), together with such recommendations as the 
        Comptroller General determines to be appropriate.
    (c) Revisions to Existing Demonstration Program.--
            (1) Extension through the implementation of the new 
        program.--Section 1866E(e)(1) of the Social Security Act (42 
        U.S.C. 1395cc-5(e)(1)) is amended by inserting ``plus the 
        period beginning at the end of such 7-year period and ending on 
        the date of the implementation of the Program under section 
        1866G'' after ``7-year period''.
            (2) Permitting existing practices to see more 
        beneficiaries.--Section 1866E(e)(5) of the Social Security Act 
        (42 U.S.C. 1395cc-5(e)(1)) is amended--
                    (A) in the second sentence, by inserting the 
                following before the period: ``plus for the period 
                beginning at the end of such seventh year and ending on 
                the date of the implementation of the Program under 
                section 1866G''; and
                    (B) by adding at the end the following new 
                sentence: ``Beginning on the date of the enactment of 
                this sentence, the limitation on the number of 
                beneficiaries that may participate in the demonstration 
                program pursuant to the first sentence shall not apply 
                with respect to independence at home medical practices 
                participating in the demonstration program as of such 
                date of enactment.''.
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