II 

110TH CONGRESS 

2D SESSION S. 3613 

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 SENATE OF THE UNITED STATES 

SEPTEMBER 26 (legislative day, SEPTEMBER 17), 2008 

Mr. WYDEN (for himself, Ms. MIKULSKI, 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 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. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Independence at Home 

3 Act of 2008’’. 

4 SEC. 2. FINDINGS. 

5 Congress makes the following findings: 

6 (1) According to the November 2007 Congres7 sional Budget Office Long Term Outlook for Health 

8 Care Spending, unless changes are made to the way 

9 health care is delivered, growing demand for re10 sources caused by rising health care costs and to a 

11 lesser extent the Nation’s expanding elderly popu12 lation will confront Americans with increasingly dif13 ficult choices between health care and other prior14 ities. However, opportunities exist to constrain 

15 health care costs without adverse health care con16 sequences. 

17 (2) Medicare beneficiaries with multiple chronic 

18 conditions account for a disproportionate share of 

19 Medicare spending compared to their representation 

20 in the overall Medicare population, and evidence sug21 gests that such patients often receive poorly coordi22 nated care, including conflicting information from 

23 health providers and different diagnoses of the same 

24 symptoms. 

25 (3) People with chronic conditions account for 

26 76 percent of all hospital admissions, 88 percent of 


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1 all prescriptions filled, and 72 percent of physician 

2 visits. 

3 (4) More than 60 percent of physicians treating 

4 patients with chronic conditions believe that their 

5 training did not adequately prepare them to coordi6 nate in-home and community services; educate pa7 tients with chronic conditions; manage the psycho8 logical and social aspects of chronic care; provide ef9 fective nutritional guidance; and manage chronic 

10 pain. 

11 (5) Recent studies cited by the Congressional 

12 Budget Office found substantial differences among 

13 regions of the country in the cost to Medicare of 

14 treating beneficiaries with multiple chronic condi15 tions with lower cost regions experiencing better out16 comes and lower mortality rates. These studies have 

17 suggested that Medicare spending could be reduced 

18 by 30 percent if more conservative practice styles 

19 were adopted, however, the current Medicare fee-for20 service program creates incentives to provide frag21 mented, high cost health care services. 

22 (6) Studies show that hospital utilization and 

23 emergency room visits for patients with multiple 

24 chronic conditions can be reduced and significant 

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1 disciplinary teams of health care professionals caring 

2 for patients in their places of residence. 

3 (7) The Independence at Home program, de4 signed to fund better health care and improved 

5 health care technology through savings it achieves, 

6 uses a patient-centered health care delivery model to 

7 permit the growing number of Medicare beneficiaries 

8 with multiple chronic conditions to remain as inde9 pendent as possible for as long as possible and to re10 ceive care in a setting that is preferred by the bene11 ficiary involved and the family of such beneficiary. 

12 (8) The Independence at Home program begins 

13 Medicare reform by creating incentives for practi14 tioners and providers to develop methods and tech15 nologies for providing better and lower cost health 

16 care to the highest cost Medicare beneficiaries with 

17 the greatest incentives provided in the case of high18 est cost beneficiaries. 

19 (9) The Independence at Home program incor20 porates lessons learned from prior demonstration 

21 projects and phase I of the Voluntary Chronic Care 

22 Improvement program under section 1807 of the So23 cial Security Act, enacted in sections 721 and 722 

24 of the Medicare Prescription Drug, Improvement 


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1 and Modernization Act of 2003 (Public Law 108– 

2 173). 

3 (10) The Independence at Home Act provides 

4 for a chronic care coordination demonstration for 

5 the highest cost Medicare beneficiaries with multiple 

6 chronic conditions that holds providers accountable 

7 for quality outcomes, patient satisfaction, and man8 datory minimum savings on an annual basis. 

9 (11) The Independence at Home Act generates 

10 savings by providing better, more coordinated care 

11 to the highest cost Medicare beneficiaries with mul12 tiple chronic conditions, reducing duplicative and un13 necessary services, and avoiding unnecessary hos14 pitalizations and emergency room visits. 

15 SEC. 3. ESTABLISHMENT OF VOLUNTARY INDEPENDENCE 

16 AT HOME CHRONIC CARE COORDINATION 

17 DEMONSTRATION PROJECT UNDER TRADI18 TIONAL MEDICARE FEE-FOR-SERVICE PRO19 GRAM. 

20 (a) IN GENERAL.—Title XVIII of the Social Security 

21 Act is amended— 

22 (1) by amending subsection (c) of section 1807 

23 (42 U.S.C. 1395b–8) to read as follows: 

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1 tion project for Independence at Home chronic care co2 ordination programs for high cost Medicare beneficiaries 

3 with multiple chronic conditions is set forth in section 

4 1807A.’’; and 

5 (2) by inserting after section 1807 the following 

6 new section: 

7 ‘‘INDEPENDENCE AT HOME CHRONIC CARE

8 COORDINATION DEMONSTRATION PROJECT

9 ‘‘SEC. 1807A. (a) IN GENERAL.— 

10 ‘‘(1) IMPLEMENTATION.—The Secretary shall, 

11 where possible, enter into agreements with at least 

12 two unaffiliated Independence at Home organiza13 tions, as described in this section, to provide chronic 

14 care coordination services for a period of three years 

15 in each of the 13 highest cost States and the Dis16 trict of Columbia and in 13 additional States that 

17 are representative of other regions of the United 

18 States. Such organizations shall have documented 

19 experience in furnishing the types of services covered 

20 by this section to eligible beneficiaries in non-institu21 tional settings using qualified teams of health care 

22 professionals that are directed by Independence at 

23 Home physicians or Independence at Home nurse 

24 practitioners and that use health information tech25 nology and individualized plans of care. 


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1 ‘‘(2) ELIGIBILITY.—Any organization shall be 

2 eligible for an Independence at Home agreement in 

3 the developmental phase if it is an Independence at 

4 Home organization (as defined in subsection (b)(7)) 

5 and has the demonstrated capacity to provide the 

6 services covered under this section to the number of 

7 eligible beneficiaries specified in subsection 

8 (e)(3)(C). No organization shall be prohibited from 

9 participating because of its small size as long as it 

10 meets the eligibility requirements of this section. 

11 ‘‘(3) INDEPENDENT EVALUATION.—The Sec12 retary shall contract for an independent evaluation 

13 of the Independence at Home demonstration project 

14 under this section with an interim report to be pro15 vided after the first year and a final report to be 

16 provided after the third year of the project. Such an 

17 evaluation shall be conducted by a contractor with 

18 knowledge of chronic care coordination programs for 

19 the targeted patient population and demonstrated 

20 experience in the evaluation of such programs. Each 

21 such report shall include an assessment of the fol22 lowing factors and shall identify the characteristics 

23 of individual Independence at Home programs that 

24 are the most effective: 

25 ‘‘(A) Quality improvement measures. 


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1 ‘‘(B) Beneficiary, caregiver, and provider 

2 satisfaction. 

3 ‘‘(C) Health outcomes appropriate for pa4 tients with multiple chronic conditions. 

5 ‘‘(D) Cost savings to the program under 

6 this title. 

7 ‘‘(4) AGREEMENTS.—The Secretary shall enter 

8 into agreements, beginning not later than one year 

9 after the date of the enactment of this section, with 

10 Independence at Home organizations that meet the 

11 participation requirements of this section, including 

12 minimum performance standards developed under 

13 subsection (e)(3), in order to provide access by eligi14 ble beneficiaries to Independence at Home programs 

15 under this section. 

16 ‘‘(5) REGULATIONS.—At least three months be17 fore entering into the first agreement under this sec18 tion, the Secretary shall publish in the Federal Reg19 ister the specifications for implementing this section. 

20 ‘‘(6) PERIODIC PROGRESS REPORTS.—Semi-an21 nually during the first year in which this section is 

22 implemented and annually thereafter during the pe23 riod of implementation of this section, the Secretary 

24 shall submit to the Committees on Ways and Means 

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1 resentatives and the Committee on Finance of the 

2 Senate a report that describes the progress of imple3 mentation of this section and explaining any vari4 ation from the Independence at Home program as 

5 described in this section. 

6 ‘‘(b) DEFINITIONS.—For purposes of this section: 

7 ‘‘(1) ACTIVITIES OF DAILY LIVING.—The term 

8 ‘activities of daily living’ means bathing, dressing, 

9 grooming, transferring, feeding, or toileting. 

10 ‘‘(2) CAREGIVER.—The term ‘caregiver’ means, 

11 with respect to an individual with a qualifying func12 tional impairment, a family member, friend, or 

13 neighbor who provides assistance to the individual. 

14 ‘‘(3) ELIGIBLE BENEFICIARY.— 

15 ‘‘(A) IN GENERAL.—The term ‘eligible 

16 beneficiary’ means, with respect to an Inde17 pendence at Home program, an individual 

18 who— 

19 ‘‘(i) is entitled to benefits under part 

20 A and enrolled under part B, but not en21 rolled in a plan under part C; 

22 ‘‘(ii) has a qualifying functional im23 pairment and has been diagnosed with two 

24 or more of the chronic conditions described 

25 in subparagraph (C); and 


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1 ‘‘(iii) within the 12 months prior to 

2 the individual first enrolling with an Inde3 pendence at Home program under this sec4 tion, has received benefits under this title 

5 for services described in each of clauses (i), 

6 (ii) and (iii) of subparagraph (D). 

7 ‘‘(B) DISQUALIFICATIONS.—Such term 

8 does not include an individual— 

9 ‘‘(i) who is receiving benefits under 

10 section 1881; 

11 ‘‘(ii) who is enrolled in a PACE pro12 gram under section 1894; 

13 ‘‘(iii) who is enrolled in (and is not 

14 disenrolled from) a chronic care improve15 ment program under section 1807; 

16 ‘‘(iv) who within the previous year has 

17 been a resident for more than 90 days in 

18 a skilled nursing facility, a nursing facility 

19 (as defined in section 1919), or any other 

20 facility identified by the Secretary; 

21 ‘‘(v) who resides in a setting that pre22 sents a danger to the safety of in-home 

23 health care providers and primary care24 givers; or 


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1 ‘‘(vi) whose enrollment in an Inde2 pendence at Home program the Secretary 

3 determines would be inappropriate. 

4 ‘‘(C) CHRONIC CONDITIONS DESCRIBED.— 

5 The chronic conditions described in this sub6 paragraph are the following: 

7 ‘‘(i) Congestive heart failure. 

8 ‘‘(ii) Diabetes. 

9 ‘‘(iii) Chronic obstructive pulmonary 

10 disease. 

11 ‘‘(iv) Ischemic heart disease. 

12 ‘‘(v) Peripheral arterial disease. 

13 ‘‘(vi) Stroke. 

14 ‘‘(vii) Alzheimer’s Disease and other 

15 dementias designated by the Secretary. 

16 ‘‘(viii) Pressure ulcers. 

17 ‘‘(ix) Hypertension. 

18 ‘‘(x) Neurodegenerative diseases des19 ignated by the Secretary which result in 

20 high costs under this title, including 

21 amyotropic lateral sclerosis (ALS), mul22 tiple sclerosis, and Parkinson’s disease. 

23 ‘‘(xi) Any other chronic condition that 

24 the Secretary identifies as likely to result 

25 in high costs to the program under this 


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1 title when such condition is present in 

2 combination with one or more of the 

3 chronic conditions specified in the pre4 ceding clauses. 

5 ‘‘(D) SERVICES DESCRIBED.—The services 

6 described in this subparagraph are the fol7 lowing: 

8 ‘‘(i) Non-elective inpatient hospital 

9 services. 

10 ‘‘(ii) Services in the emergency de11 partment of a hospital. 

12 ‘‘(iii) Any of the following services: 

13 ‘‘(I) Extended care services. 

14 ‘‘(II) Services in an acute reha15 bilitation facility. 

16 ‘‘(III) Home health services. 

17 ‘‘(4) INDEPENDENCE AT HOME ASSESSMENT.— 

18 The term ‘Independence at Home assessment’ 

19 means, with respect to an eligible beneficiary, a com20 prehensive medical history, physical examination, 

21 and assessment of the beneficiary’s clinical and func22 tional status that— 

23 ‘‘(A) is conducted by— 


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1 ‘‘(i) an Independence at Home physi2 cian or an Independence at Home nurse 

3 practitioner; 

4 ‘‘(ii) a physician assistant, nurse prac5 titioner, or clinical nurse specialist, as de6 fined in section 1861(aa)(5), who is em7 ployed by an Independence at Home orga8 nization and is working in collaboration 

9 with an Independence at Home physician 

10 or Independence at Home nurse practi11 tioner; or 

12 ‘‘(iii) any other health care profes13 sional that meets such conditions as the 

14 Secretary may specify; and 

15 ‘‘(B) includes an assessment of— 

16 ‘‘(i) activities of daily living and other 

17 co-morbidities; 

18 ‘‘(ii) medications and medication ad19 herence; 

20 ‘‘(iii) affect, cognition, executive func21 tion, and presence of mental disorders; 

22 ‘‘(iv) functional status, including mo23 bility, balance, gait, risk of falling, and 

24 sensory function; 


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1 ‘‘(v) social functioning and social inte2 gration; 

3 ‘‘(vi) environmental needs and a safe4 ty assessment; 

5 ‘‘(vii) the ability of the beneficiary’s 

6 primary caregiver to assist with the bene7 ficiary’s care as well as the caregiver’s own 

8 physical and emotional capacity, education, 

9 and training; 

10 ‘‘(viii) whether the beneficiary is likely 

11 to benefit from an Independence at Home 

12 program; 

13 ‘‘(ix) whether the conditions in the 

14 beneficiary’s home or place of residence 

15 would permit the safe provision of services 

16 in the home or residence, respectively, 

17 under an Independence at Home program; 

18 and 

19 ‘‘(x) other factors determined appro20 priate by the Secretary. 

21 ‘‘(5) INDEPENDENCE AT HOME CARE TEAM.— 

22 The term ‘Independence at Home care team’— 

23 ‘‘(A) means, with respect to a participant, 

24 a team of qualified individuals that provides 


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1 services to the participant as part of an Inde2 pendence at Home program; and 

3 ‘‘(B) includes an Independence at Home 

4 physician or an Independence at Home nurse 

5 practitioner and an Independence at Home co6 ordinator (who may also be an Independence at 

7 Home physician or an Independence at Home 

8 nurse practitioner). 

9 ‘‘(6) INDEPENDENCE AT HOME COORDI10 NATOR.—The term ‘Independence at Home coordi11 nator’ means, with respect to a participant, an indi12 vidual who— 

13 ‘‘(A) is employed by an Independence at 

14 Home organization and is responsible for co15 ordinating all of the elements of the partici16 pant’s Independence at Home plan; 

17 ‘‘(B) is a licensed health professional, such 

18 as a physician, registered nurse, nurse practi19 tioner, clinical nurse specialist, physician assist20 ant, or other health care professional as the 

21 Secretary determines appropriate, who has at 

22 least one year of experience providing and co23 ordinating medical and related services for indi24 viduals in their homes; and 


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1 ‘‘(C) serves as the primary point of contact 

2 responsible for communications with the partici3 pant and for facilitating communications with 

4 other health care providers under the plan. 

5 ‘‘(7) INDEPENDENCE AT HOME ORGANIZA6 TION.—The term ‘Independence at Home organiza7 tion’ means a provider of services, a physician or 

8 physician group practice, a nurse practitioner or 

9 nurse practitioner group practice, or other legal enti10 ty which receives payment for services furnished 

11 under this title (other than only under this section) 

12 and which— 

13 ‘‘(A) has entered into an agreement under 

14 subsection (a)(2) to provide an Independence at 

15 Home program under this section; 

16 ‘‘(B)(i) is able to provide all of the ele17 ments of the Independence at Home plan in a 

18 participant’s home or place of residence, or 

19 ‘‘(ii) if the organization is not able to pro20 vide all such elements in such home or resi21 dence, has adequate mechanisms for ensuring 

22 the provision of such elements by one or more 

23 qualified entities; 

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1 tioners, or physician assistants available to re2 spond to patient emergencies 24 hours a day, 

3 seven days a week; 

4 ‘‘(D) accepts all eligible beneficiaries from 

5 the organization’s service area except to the ex6 tent that qualified staff are not available; and 

7 ‘‘(E) meets other requirements for such an 

8 organization under this section. 

9 ‘‘(8) INDEPENDENCE AT HOME PHYSICIAN.— 

10 The term ‘Independence at Home physician’ means 

11 a physician who— 

12 ‘‘(A) is employed by or affiliated with an 

13 Independence at Home organization, as re14 quired under paragraph (7)(C), or has another 

15 contractual relationship with the Independence 

16 at Home organization that requires the physi17 cian to be responsible for the plans of care for 

18 the physician’s patients; 

19 ‘‘(B) is certified— 

20 ‘‘(i) by the American Board of Family 

21 Physicians, the American Board of Inter22 nal Medicine, the American Osteopathic 

23 Board of Family Physicians, the American 

24 Osteopathic Board of Internal Medicine, 

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1 cine, or the American Board of Physical 

2 Medicine and Rehabilitation; or 

3 ‘‘(ii) by a Board recognized by the 

4 American Board of Medical Specialties and 

5 determined by the Secretary to be appro6 priate for the Independence at Home pro7 gram; 

8 ‘‘(C) has— 

9 ‘‘(i) a certification in geriatric medi10 cine as provided by American Board of 

11 Medical Specialties; or 

12 ‘‘(ii) passed the clinical competency 

13 examination of the American Academy of 

14 Home Care Physicians and has substantial 

15 experience in the delivery of medical care 

16 in the home, including at least two years 

17 of experience in the management of Medi18 care patients and one year of experience in 

19 home-based medical care including at least 

20 200 house calls; and 

21 ‘‘(D) has furnished services during the pre22 vious 12 months for which payment is made 

23 under this title. 


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1 ‘‘(9) INDEPENDENCE AT HOME NURSE PRACTI2 TIONER.—The term ‘Independence at Home nurse 

3 practitioner’ means a nurse practitioner who— 

4 ‘‘(A) is employed by or affiliated with an 

5 Independence at Home organization, as re6 quired under paragraph (7)(C), or has another 

7 contractual relationship with the Independence 

8 at Home organization that requires the nurse 

9 practitioner to be responsible for the plans of 

10 care for the nurse practitioner’s patients; 

11 ‘‘(B) practices in accordance with State 

12 law regarding scope of practice for nurse practi13 tioners; 

14 ‘‘(C) is certified— 

15 ‘‘(i) as a Gerontologic Nurse Practi16 tioner by the American Academy of Nurse 

17 Practitioners Certification Program or the 

18 American Nurses Credentialing Center; or 

19 ‘‘(ii) as a family nurse practitioner or 

20 adult nurse practitioner by the American 

21 Academy of Nurse Practitioners Certifi22 cation Board or the American Nurses 

23 Credentialing Center and holds a certifi24 cate of Added Qualification in gerontology, 

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1 vided by the American Academy of Nurse 

2 Practitioners, the American Nurses 

3 Credentialing Center or a national nurse 

4 practitioner certification board deemed by 

5 the Secretary to be appropriate for an 

6 Independence at Home program; and 

7 ‘‘(D) has furnished services during the pre8 vious 12 months for which payment is made 

9 under this title. 

10 ‘‘(10) INDEPENDENCE AT HOME PLAN.—The 

11 term ‘Independence at Home plan’ means a plan es12 tablished under subsection (d)(2) for a specific par13 ticipant in an Independence at Home program. 

14 ‘‘(11) INDEPENDENCE AT HOME PROGRAM.— 

15 The term ‘Independence at Home program’ means a 

16 program described in subsection (d) that is operated 

17 by an Independence at Home organization. 

18 ‘‘(12) PARTICIPANT.—The term ‘participant’ 

19 means an eligible beneficiary who has voluntarily en20 rolled in an Independence at Home program. 

21 ‘‘(13) QUALIFIED ENTITY.—The term ‘qualified 

22 entity’ means a person or organization that is li23 censed or otherwise legally permitted to provide the 

24 specific element (or elements) of an Independence at 

25 Home plan that the entity has agreed to provide. 


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1 ‘‘(14) QUALIFYING FUNCTIONAL IMPAIR2 MENT.—The term ‘qualifying functional impairment’ 

3 means an inability to perform, without the assist4 ance of another person, two or more activities of 

5 daily living. 

6 ‘‘(c) IDENTIFICATION AND ENROLLMENT OF PRO7 SPECTIVE PROGRAM PARTICIPANTS.— 

8 ‘‘(1) NOTICE TO ELIGIBLE INDEPENDENCE AT

9 HOME BENEFICIARIES.—The Secretary shall develop 

10 a model notice to be made available to Medicare 

11 beneficiaries (and to their caregivers) who are poten12 tially eligible for an Independence at Home program 

13 by participating providers and by Independence at 

14 Home programs. Such notice shall include the fol15 lowing information: 

16 ‘‘(A) A description of the potential advan17 tages to the beneficiary participating in an 

18 Independence at Home program. 

19 ‘‘(B) A description of the eligibility re20 quirements to participate. 

21 ‘‘(C) Notice that participation is voluntary. 

22 ‘‘(D) A statement that all other Medicare 

23 benefits remain available to beneficiaries who 

24 enroll in an Independence at Home program. 


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1 ‘‘(E) Notice that those who enroll in an 

2 Independence at Home program may have co3 payments for house calls by Independence at 

4 Home physicians or by Independence at Home 

5 nurse practitioners reduced or eliminated at the 

6 discretion of the Independence at Home physi7 cian or Independence at Home nurse practi8 tioner involved. 

9 ‘‘(F) A description of the services that 

10 could potentially be provided under an Inde11 pendence at Home plan. 

12 ‘‘(G) A description of the method for par13 ticipating, or withdrawing from participation, in 

14 an Independence at Home program or becoming 

15 no longer eligible to so participate. 

16 ‘‘(2) VOLUNTARY PARTICIPATION AND

17 CHOICE.—An eligible beneficiary may participate in 

18 an Independence at Home program through enroll19 ment in such program on a voluntary basis and may 

20 terminate such participation at any time. Such a 

21 beneficiary may also receive Independence at Home 

22 services from the Independence at Home organiza23 tion of the beneficiary’s choice but may not receive 

24 Independence at Home services from more than one 

25 Independence at Home organization at a time. 


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1 ‘‘(d) INDEPENDENCE AT HOME PROGRAM REQUIRE2 MENTS.— 

3 ‘‘(1) IN GENERAL.—Each Independence at 

4 Home program shall, for each participant enrolled in 

5 the program— 

6 ‘‘(A) designate— 

7 ‘‘(i) an Independence at Home physi8 cian or an Independence at Home nurse 

9 practitioner; and 

10 ‘‘(ii) an Independence at Home coor11 dinator; 

12 ‘‘(B) have a process to ensure that the 

13 participant received an Independence at Home 

14 assessment before enrollment in the program; 

15 ‘‘(C) with the participation of the partici16 pant (or the participant’s representative or 

17 caregiver), an Independence at Home physician 

18 or an Independence at Home nurse practitioner, 

19 and Independence at Home coordinator, develop 

20 an Independence at Home plan for the partici21 pant in accordance with paragraph (2); 

22 ‘‘(D) ensure that the participant receives 

23 an Independence at Home assessment at least 

24 annually after the original assessment to ensure 


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1 that the Independence at Home plan for the 

2 participant remains current and appropriate; 

3 ‘‘(E) implement all of the elements of the 

4 participant’s Independence at Home plan and 

5 in instances in which the Independence at 

6 Home organization does not provide specific ele7 ments of the Independence at Home plan, en8 sure that qualified entities successfully imple9 ment those specific elements; 

10 ‘‘(F) provide for an electronic medical 

11 record and electronic health information tech12 nology to coordinate the participant’s care and 

13 to exchange information with the Medicare pro14 gram and electronic monitoring and commu15 nication technologies and mobile diagnostic and 

16 therapeutic technologies as appropriate and ac17 cepted by the participant; and 

18 ‘‘(G) respect the participant’s right to 

19 health information privacy and obtain permis20 sion from the participant (or responsible per21 son) for the use and disclosure of identifiable 

22 health information necessary for treatment, 

23 payment, or health care operations. 

24 ‘‘(2) INDEPENDENCE AT HOME PLAN.— 


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1 ‘‘(A) IN GENERAL.—An Independence at 

2 Home plan for a participant shall be developed 

3 with the participant, an Independence at Home 

4 physician or an Independence at Home nurse 

5 practitioner, an Independence at Home coordi6 nator, and, if appropriate, one or more of the 

7 participant’s caregivers and shall— 

8 ‘‘(i) document the chronic conditions, 

9 co-morbidities, and other health needs 

10 identified in the participant’s Independence 

11 at Home assessment; 

12 ‘‘(ii) determine which elements of an 

13 Independence at Home plan described in 

14 subparagraph (C) are appropriate for the 

15 participant; and 

16 ‘‘(iii) identify the qualified entity re17 sponsible for providing each element of 

18 such plan. 

19 ‘‘(B) COMMUNICATION OF INDIVIDUALIZED

20 INDEPENDENCE AT HOME PLAN TO THE INDE21 PENDENCE AT HOME COORDINATOR.—If the 

22 Independence at Home physician or Independ23 ence at Home nurse practitioner responsible for 

24 conducting the participant’s Independence at 

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1 ence at Home plan is not the participant’s 

2 Independence at Home coordinator, the Inde3 pendence at Home physician or Independence 

4 at Home nurse practitioner is responsible for 

5 ensuring that the participant’s Independence at 

6 Home coordinator has such plan and is familiar 

7 with the requirements of the plan and has the 

8 appropriate contact information for all of the 

9 members of the Independence at Home care 

10 team. 

11 ‘‘(C) ELEMENTS OF INDEPENDENCE AT

12 HOME PLAN.—An Independence at Home orga13 nization shall have the capability to provide, di14 rectly or through a qualified entity, and shall 

15 offer all of the following elements of an Inde16 pendence at Home plan to the extent they are 

17 appropriate and accepted by a participant: 

18 ‘‘(i) Self-care education and preven19 tive care consistent with the participant’s 

20 condition. 

21 ‘‘(ii) Coordination of all medical treat22 ment furnished to the participant, regard23 less of whether such treatment is covered 

24 and available to the participant under this 

25 title. 


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1 ‘‘(iii) Information about, and access 

2 to, hospice care. 

3 ‘‘(iv) Pain and palliative care and end4 of-life care. 

5 ‘‘(v) Education for primary caregivers 

6 and family members. 

7 ‘‘(vi) Caregiver counseling services 

8 and information about, and referral to, 

9 other caregiver support and health care 

10 services in the community. 

11 ‘‘(vii) Monitoring and management of 

12 medications as well as assistance to par13 ticipants and their caregivers with respect 

14 to selection of a prescription drug plan 

15 under part D that best meets the needs of 

16 the participant’s chronic conditions. 

17 ‘‘(viii) Referral to social services, such 

18 as personal care, meals, volunteers, and in19 dividual and family therapy. 

20 ‘‘(ix) Access to phlebotomy and ancil21 lary laboratory and imaging services, in22 cluding point of care laboratory and imag23 ing diagnostics. 

24 ‘‘(3) PRIMARY TREATMENT ROLE WITHIN AN

25 INDEPENDENCE AT HOME CARE TEAM.—An IndeVerDate Aug 31 2005 07:14 Oct 02, 2008 Jkt 069200 PO 00000 Frm 00027 Fmt 6652 Sfmt 6201 E:\BILLS\S3613.IS S3613

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1 pendence at Home physician or an Independence at 

2 Home nurse practitioner may assume the primary 

3 treatment role as permitted under State law. 

4 ‘‘(4) ADDITIONAL RESPONSIBILITIES.— 

5 ‘‘(A) OUTCOMES REPORT.—Each Inde6 pendence at Home organization offering an 

7 Independence at Home program shall monitor 

8 and report to the Secretary, in a manner speci9 fied by the Secretary, on— 

10 ‘‘(i) patient outcomes; 

11 ‘‘(ii) beneficiary, caregiver, and pro12 vider satisfaction with respect to coordina13 tion of the participant’s care; and 

14 ‘‘(iii) the achievement of mandatory 

15 minimum savings described in subsection 

16 (e)(6). 

17 ‘‘(B) ADDITIONAL REQUIREMENTS.—Each 

18 such organization and program shall comply 

19 with such additional requirements as the Sec20 retary may specify. 

21 ‘‘(e) TERMS AND CONDITIONS.— 

22 ‘‘(1) IN GENERAL.—An agreement under this 

23 section with an Independence at Home organization 

24 shall contain such terms and conditions as the Sec25 retary may specify consistent with this section. 


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1 ‘‘(2) CLINICAL, QUALITY IMPROVEMENT, AND

2 FINANCIAL REQUIREMENTS.—The Secretary may 

3 not enter into an agreement with such an organiza4 tion under this section for the operation of an Inde5 pendence at Home program unless— 

6 ‘‘(A) the program and organization meet 

7 the requirements of subsection (d), minimum 

8 quality and performance standards developed 

9 under paragraph (3), and such clinical, quality 

10 improvement, financial, and other requirements 

11 as the Secretary deems to be appropriate for 

12 participants to be served; and 

13 ‘‘(B) the organization demonstrates to the 

14 satisfaction of the Secretary that the organiza15 tion is able to assume financial risk for per16 formance under the agreement with respect to 

17 payments made to the organization under such 

18 agreement through available reserves, reinsur19 ance, or withholding of funding provided under 

20 this title, or such other means as the Secretary 

21 determines appropriate. 

22 ‘‘(3) MINIMUM QUALITY AND PERFORMANCE

23 STANDARDS.— 

24 ‘‘(A) IN GENERAL.—The Secretary shall 

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1 formance standards for Independence at Home 

2 organizations and programs. 

3 ‘‘(B) STANDARDS TO BE INCLUDED.— 

4 Such standards shall include measures of— 

5 ‘‘(i) participant outcomes; 

6 ‘‘(ii) satisfaction of the beneficiary, 

7 caregiver, and provider involved; and 

8 ‘‘(iii) cost savings consistent with 

9 paragraph (6). 

10 ‘‘(C) MINIMUM PARTICIPATION STAND11 ARD.—Such standards shall include a require12 ment that, for any year after the first year, an 

13 Independence at Home program had an average 

14 number of participants during the previous year 

15 of at least 100 participants. 

16 ‘‘(4) TERM OF AGREEMENT AND MODIFICA17 TION.—The agreement under this subsection shall 

18 be, subject to paragraphs (3)(C) and (5), for a pe19 riod of three years, and the terms and conditions 

20 may be modified during the contract period only 

21 upon the request of the Independence at Home orga22 nization. 

23 ‘‘(5) TERMINATION AND NON-RENEWAL OF

24 AGREEMENT.— 


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1 ‘‘(A) IN GENERAL.—If the Secretary deter2 mines that an Independence at Home organiza3 tion has failed to meet the minimum perform4 ance standards under paragraph (3) or other 

5 requirements under this section, the Secretary 

6 may terminate the agreement of the organiza7 tion at the end of the contract year. 

8 ‘‘(B) REQUIRED TERMINATION WHERE

9 RISK TO HEALTH OR SAFETY OF A PARTICI10 PANT.—The Secretary shall terminate an agree11 ment with an Independence at Home organiza12 tion at any time the Secretary determines that 

13 the care being provided by such organization 

14 poses a threat to the health and safety of a par15 ticipant. 

16 ‘‘(C) TERMINATION BY INDEPENDENCE AT

17 HOME ORGANIZATIONS.—Notwithstanding any 

18 other provision of this subsection, an Independ19 ence at Home organization may terminate an 

20 agreement with the Secretary under this section 

21 to provide an Independence at Home program 

22 at the end of a contract year if the organization 

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1 fore the end of such year. Paragraphs (6), (8), 

2 and (9)(B) shall apply to the organization until 

3 the date of termination. 

4 ‘‘(D) NOTICE OF INVOLUNTARY TERMI5 NATION.—The Secretary shall notify the par6 ticipants in an Independence at Home program 

7 as soon as practicable if a determination is 

8 make to terminate an agreement with the Inde9 pendence at Home organization involuntarily as 

10 provided in subparagraphs (A) and (B). Such 

11 notice shall inform the beneficiary of any other 

12 Independence at Home organizations that 

13 might be available to the beneficiary. 

14 ‘‘(6) MANDATORY MINIMUM SAVINGS.— 

15 ‘‘(A) IN GENERAL.—Under an agreement 

16 under this subsection, each Independence at 

17 Home organization shall ensure that during any 

18 year of the agreement for its Independence at 

19 Home program, there is an aggregate savings 

20 in the cost to the program under this title for 

21 participating beneficiaries, as calculated under 

22 subparagraph (B), that is not less than the 

23 product of— 

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1 curred under parts A, B, and D if those 

2 beneficiaries had not participated in the 

3 Independence at Home program; and 

4 ‘‘(ii) the number of participant5 months for that year. 

6 ‘‘(B) COMPUTATION OF AGGREGATE SAV7 INGS.— 

8 ‘‘(i) MODEL FOR CALCULATING SAV9 INGS.—The Secretary shall contract with a 

10 nongovernmental organization or academic 

11 institution to independently develop an an12 alytical model for determining whether an 

13 Independence at Home program achieves 

14 at least savings required under subpara15 graph (A) relative to costs that would have 

16 been incurred by Medicare in the absence 

17 of Independence at Home programs. The 

18 analytical model developed by the inde19 pendent research organization for making 

20 these determinations shall utilize state-of21 the-art econometric techniques, such as 

22 Heckman’s selection correction methodolo23 gies, to account for sample selection bias, 

24 omitted variable bias, or problems with 

25 endogeneity. 


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1 ‘‘(ii) APPLICATION OF THE MODEL.— 

2 Using the model developed under clause 

3 (i), the Secretary shall compare the actual 

4 costs to Medicare of beneficiaries partici5 pating in an Independence at Home pro6 gram to the predicted costs to Medicare of 

7 such beneficiaries to determine whether an 

8 Independence at Home program achieves 

9 the savings required under subparagraph 

10 (A). 

11 ‘‘(iii) REVISIONS OF THE MODEL.— 

12 The Secretary shall require that the model 

13 developed under clause (i) for determining 

14 savings shall be designed according to in15 structions that will control, or adjust for, 

16 inflation as well as risk factors including, 

17 age, race, gender, disability status, socio18 economic status, region of country (such as 

19 State, county, metropolitan statistical area, 

20 or zip code), and such other factors as the 

21 Secretary determines to be appropriate, in22 cluding adjustment for prior health care 

23 utilization. The Secretary may add to, 

24 modify, or substitute for such adjustment 

25 factors if such changes will improve the 


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1 sensitivity or specificity of the calculation 

2 of costs savings. 

3 ‘‘(iv) PARTICIPANT-MONTH.—In mak4 ing the calculation described in subpara5 graph (A), each month or part of a month 

6 in a program year that a beneficiary par7 ticipates in an Independence at Home pro8 gram shall be counted as a ‘participant9 month’. 

10 ‘‘(C) NOTICE OF SAVINGS CALCULATION.— 

11 No later than 120 days before the beginning of 

12 any Independence at Home program year, the 

13 Secretary shall publish in the Federal Register 

14 a description of the model developed under sub15 paragraph (B)(i) and information for calcu16 lating savings required under subparagraph 

17 (A), including any revisions, sufficient to permit 

18 Independence at Home organizations to deter19 mine the savings they will be required to 

20 achieve during the program year to meet the 

21 savings requirement under such subparagraph. 

22 In order to facilitate this notice, the Secretary 

23 may designate a single annual date for the be24 ginning of all Independence at Home program 


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1 years that shall not be later than one year from 

2 the date of enactment of this section. 

3 ‘‘(7) MANNER OF PAYMENT.—Subject to para4 graph (8), payments shall be made by the Secretary 

5 to an Independence at Home organization at a rate 

6 negotiated between the Secretary and the organiza7 tion under the agreement for— 

8 ‘‘(A) Independence at Home assessments; 

9 and 

10 ‘‘(B) on a per-participant, per-month basis 

11 for the items and services required to be pro12 vided or made available under subsection (d). 

13 ‘‘(8) ENSURING MANDATORY MINIMUM SAV14 INGS.—The Secretary shall require any Independ15 ence at Home organization that fails in any year to 

16 achieve the mandatory minimum savings described 

17 in paragraph (6) to provide those savings by refund18 ing payments made to the organization under para19 graph (7) during such year. 

20 ‘‘(9) BUDGET NEUTRAL PAYMENT CONDI21 TION.— 

22 ‘‘(A) IN GENERAL.—Under this section, 

23 the Secretary shall ensure that the cumulative, 

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1 pants in Independence at Home programs and 

2 funds paid to Independence at Home organiza3 tions under this section, shall not exceed the 

4 Medicare program benefit expenditures under 

5 such parts that the Secretary estimates would 

6 have been made for such participants in the ab7 sence of such programs. 

8 ‘‘(B) TREATMENT OF SAVINGS.—If an 

9 Independence at Home organization achieves 

10 aggregate savings in a year in excess of the 

11 mandatory minimum savings described in para12 graph (6), 80 percent of such aggregate savings 

13 shall be paid to the organization and the re14 mainder shall be retained by the programs 

15 under this title. 

16 ‘‘(f) WAIVER OF COINSURANCE FOR HOUSE

17 CALLS.—A physician or nurse practitioner furnishing 

18 services in the home or residence of a participant in an 

19 Independence at Home program may waive collection of 

20 any coinsurance that might otherwise be payable under 

21 section 1833(a) with respect to such services. 

22 ‘‘(g) REPORT.—Not later than one year after the end 

23 of the Independence at Home demonstration project under 

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1 port on such project. Such report shall include information 

2 on— 

3 ‘‘(1) whether Independence at Home programs 

4 under the project met the performance standards for 

5 beneficiary, caregiver, and provider satisfaction; and 

6 ‘‘(2) participant outcomes and cost savings, as 

7 well as the characteristics of the programs that were 

8 most effective and whether the participant eligibility 

9 criteria identified beneficiaries who were in the top 

10 ten percent of the highest cost Medicare bene11 ficiaries.’’. 

12 (b) CONFORMING AMENDMENTS.— 

13 (1) Section 1833(a) of such Act (42 U.S.C. 

14 1395l(a)) is amended, in the matter before para15 graph (1), by inserting ‘‘and section 1807A(f)’’ after 

16 ‘‘section 1876’’. 

17 (2) Section 1128B(b)(3) of such Act (42 U.S.C. 

18 1320a–7b(b)(3)) is amended— 

19 (A) by striking ‘‘and’’ at the end of sub20 paragraph (G); 

21 (B) by striking ‘‘1853(a)(4).’’ at the end of 

22 the first subparagraph (H) and inserting 

23 ‘‘1853(a)(4);’’; 

24 (C) by redesignating the second subpara25 graph (H) as subparagraph (I) and by striking 


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1 the period at the end and inserting ‘‘; and’’; 

2 and 

3 (D) by adding at the end the following new 

4 subparagraph: 

5 ‘‘(J) a waiver of coinsurance under section 

6 1807A(f).’’. 

Æ 


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