II 

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. 

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 2009’’. 

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) Studies show that hospital utilization and 

4 emergency room visits for patients with multiple 

5 chronic conditions can be reduced and significant 

6 savings can be achieved through the use of inter7 disciplinary teams of health care professionals caring 

8 for patients in their places of residence. 

9 (5) The Independence at Home Act creates a 

10 chronic care coordination pilot project to bring pri11 mary care medical services to the highest cost Medi12 care beneficiaries with multiple chronic conditions in 

13 their home or place of residence so that they may be 

14 as independent as possible for as long as possible in 

15 a comfortable setting. 

16 (6) The Independence at Home Act generates 

17 savings by providing better, more coordinated care 

18 across all treatment settings to the highest cost 

19 Medicare beneficiaries with multiple chronic condi20 tions, reducing duplicative and unnecessary services, 

21 and avoiding unnecessary hospitalizations, nursing 

22 home admissions, and emergency room visits. 

23 (7) The Independence at Home Act holds pro24 viders accountable for improving beneficiary out25 comes, ensuring patient and caregiver satisfaction, 


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1 and achieving cost savings to Medicare on an annual 

2 basis. 

3 (8) The Independence at Home Act creates in4 centives for practitioners and providers to develop 

5 methods and technologies for providing better and 

6 lower cost health care to the highest cost Medicare 

7 beneficiaries with the greatest incentives provided in 

8 the case of highest cost beneficiaries. 

9 (9) The Independence at Home Act contains 

10 the central elements of proven home-based primary 

11 care delivery models that have been utilized for years 

12 by the Department of Veterans Affairs and ‘‘house 

13 calls’’ programs across the country to deliver coordi14 nated care for chronic conditions in the comfort of 

15 a patient’s home or place of residence. 

16 SEC. 3. ESTABLISHMENT OF VOLUNTARY INDEPENDENCE 

17 AT HOME CHRONIC CARE COORDINATION 

18 PILOT PROJECT UNDER TRADITIONAL MEDI19 CARE FEE-FOR-SERVICE PROGRAM. 

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: 

24 ‘‘(c) INDEPENDENCE AT HOME CHRONIC CARE CO25 ORDINATION PILOT PROJECT.—A pilot project for IndeVerDate Nov 24 2008 18:09 May 26, 2009 Jkt 079200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S1131.IS S1131

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1 pendence at Home chronic care coordination programs for 

2 high cost Medicare beneficiaries with multiple chronic con3 ditions is set forth in section 1807A.’’; and 

4 (2) by inserting after section 1807 the following 

5 new section: 

6 ‘‘INDEPENDENCE AT HOME CHRONIC CARE

7 COORDINATION PILOT PROJECT

8 ‘‘SEC. 1807A. (a) IMPLEMENTATION.— 

9 ‘‘(1) IN GENERAL.—The Secretary shall provide 

10 for the phased in development, implementation, and 

11 evaluation of Independence at Home programs de12 scribed in this section to meet the following objec13 tives: 

14 ‘‘(A) To improve patient outcomes, com15 pared to comparable beneficiaries who do not 

16 participate in such a program, through reduced 

17 hospitalizations, nursing home admissions, or 

18 emergency room visits, increased symptom self19 management, and similar results. 

20 ‘‘(B) To improve satisfaction of patients 

21 and caregivers, as demonstrated through a 

22 quantitative pre-test and post-test survey devel23 oped by the Secretary that measures patient 

24 and caregiver satisfaction of care coordination, 

25 educational information, timeliness of response, 

26 and similar care features. 


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1 ‘‘(C) To achieve a minimum of 5 percent 

2 cost savings in the care of beneficiaries under 

3 this title suffering from multiple high cost 

4 chronic diseases. 

5 ‘‘(2) INITIAL IMPLEMENTATION (PHASE I).— 

6 ‘‘(A) IN GENERAL.—In carrying out this 

7 section and to the extent possible, the Secretary 

8 shall enter into agreements with at least two 

9 unaffiliated Independence at Home organiza10 tions in each of the 13 highest cost States 

11 (based on average per capita expenditures per 

12 State under this title), in the District of Colum13 bia, and in 13 additional States that are rep14 resentative of other regions of the United 

15 States and include medically underserved rural 

16 and urban areas, to provide chronic care coordi17 nation services for a period of three years or 

18 until those agreements are terminated by the 

19 Secretary. Such agreements under this para20 graph shall continue in effect until the Sec21 retary makes the determination described in 

22 paragraph (3) or until those agreements are 

23 supplanted by new agreements under such 

24 paragraph. The phase of implementation under 


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1 this paragraph is referred to in this section as 

2 the ‘initial implementation’ phase or ‘phase I’. 

3 ‘‘(B) PREFERENCE.—In selecting Inde4 pendence at Home organizations under this 

5 paragraph, the Secretary shall give a pref6 erence, to the extent practicable, to organiza7 tions that— 

8 ‘‘(i) have documented experience in 

9 furnishing the types of services covered by 

10 this section to eligible beneficiaries in the 

11 home or place of residence using qualified 

12 teams of health care professionals that are 

13 directed by individuals who have the quali14 fications of Independence at Home physi15 cians, or in cases when such direction is 

16 provided by an Independence at Home 

17 physician to a physician assistant who has 

18 at least one year of experience providing 

19 gerontological medical and related services 

20 for chronically ill individuals in their 

21 homes, or other similar qualification as de22 termined by the Secretary to be appro23 priate for the Independence at Home pro24 gram, by the physician assistant acting 

25 under the supervision of an Independence 


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1 at Home physician and as permitted under 

2 State law, or Independence at Home nurse 

3 practitioners; 

4 ‘‘(ii) have the capacity to provide serv5 ices covered by this section to at least 150 

6 eligible beneficiaries; and 

7 ‘‘(iii) use electronic medical records, 

8 health information technology, and individ9 ualized plans of care. 

10 ‘‘(3) EXPANDED IMPLEMENTATION PHASE

11 (PHASE II).— 

12 ‘‘(A) IN GENERAL.—For periods beginning 

13 after the end of the 3-year initial implementa14 tion period under paragraph (2), subject to sub15 paragraph (B), the Secretary shall renew agree16 ments described in paragraph (2) with Inde17 pendence at Home organization that have met 

18 all 3 objectives specified in paragraph (1) and 

19 enter into agreements described in paragraph 

20 (2) with any other organization that is located 

21 in any State or the District of Columbia, that 

22 was not an Independence at Home organization 

23 during the initial implementation period, and 

24 that meets the qualifications of an Independ25 ence at Home organization under this section. 


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1 The Secretary may terminate and not renew 

2 such an agreement with an organization that 

3 has not met such objectives during the initial 

4 implementation period. The phase of implemen5 tation under this paragraph is referred to in 

6 this section as the ‘expanded implementation’ 

7 phase or ‘phase II’. 

8 ‘‘(B) CONTINGENCY.—The expanded im9 plementation under subparagraph (A) shall not 

10 occur if the Secretary finds, not later than 60 

11 days after the date of issuance of the inde12 pendent evaluation under paragraph (5), that 

13 continuation of the Independence at Home 

14 project is not in the best interest of bene15 ficiaries under this title or in the best interest 

16 of Federal health care programs. 

17 ‘‘(4) ELIGIBILITY.—No organization shall be 

18 prohibited from participating under this section dur19 ing expanded implementation phase under para20 graph (3) (and, to the extent practicable, during ini21 tial implementation phase under paragraph (2)) be22 cause of its small size as long as it meets the eligi23 bility requirements of this section. 

24 ‘‘(5) INDEPENDENT EVALUATIONS.— 


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

2 contract for an independent evaluation of the 

3 initial implementation phase under paragraph 

4 (2) with an interim report to Congress to be 

5 provided on such evaluation as soon as prac6 ticable after the first year of such phase and a 

7 final report to be provided to Congress as soon 

8 as practicable following the conclusion of the 

9 initial implementation phase, but not later than 

10 6 months following the end of such phase. Such 

11 an evaluation shall be conducted by individuals 

12 with knowledge of chronic care coordination 

13 programs for the targeted patient population 

14 and demonstrated experience in the evaluation 

15 of such programs. 

16 ‘‘(B) INFORMATION TO BE INCLUDED.— 

17 Each such report shall include an assessment of 

18 the following factors and shall identify the char19 acteristics of individual Independence at Home 

20 programs that are the most effective in pro21 ducing improvements in— 

22 ‘‘(i) beneficiary, caregiver, and pro23 vider satisfaction; 


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1 ‘‘(ii) health outcomes appropriate for 

2 patients with multiple chronic diseases; 

3 and 

4 ‘‘(iii) cost savings to the program 

5 under this title, such as in reducing— 

6 ‘‘(I) hospital and skilled nursing 

7 facility admission rates and lengths of 

8 stay; 

9 ‘‘(II) hospital readmission rates; 

10 and 

11 ‘‘(III) emergency department vis12 its. 

13 ‘‘(C) BREAKDOWN BY CONDITION.—Each 

14 such report shall include data on performance 

15 of Independence at Home organizations in re16 sponding to the needs of eligible beneficiaries 

17 with specific chronic conditions and combina18 tions of conditions, as well as the overall eligible 

19 beneficiary population. 

20 ‘‘(6) AGREEMENTS.— 

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

22 enter into agreements, beginning not later than 

23 one year after the date of the enactment of this 

24 section, with Independence at Home organiza25 tions that meet the participation requirements 


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1 of this section, including minimum performance 

2 standards developed under subsection (e)(3), in 

3 order to provide access by eligible beneficiaries 

4 to Independence at Home programs under this 

5 section. 

6 ‘‘(B) AUTHORITY.—If the Secretary deems 

7 it necessary to serve the best interest of the 

8 beneficiaries under this title or the best interest 

9 of Federal health care programs, the Secretary 

10 may— 

11 ‘‘(i) require screening of all potential 

12 Independence at Home organizations, in13 cluding owners (such as through 

14 fingerprinting, licensure checks, site-visits, 

15 and other database checks), before enter16 ing into an agreement; 

17 ‘‘(ii) require a provisional period dur18 ing which a new Independence at Home or19 ganization would be subject to enhanced 

20 oversight (such as prepayment review, un21 announced site visits, and payment caps); 

22 and 

23 ‘‘(iii) require applicants to disclose 

24 previous affiliation with entities that have 

25 uncollected Medicare or Medicaid debt, and 


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1 authorize the denial of enrollment if the 

2 Secretary determines that these affiliations 

3 pose undue risk to the program. 

4 ‘‘(7) REGULATIONS.—At least three months be5 fore entering into the first agreement under this sec6 tion, the Secretary shall publish in the Federal Reg7 ister the specifications for implementing this section. 

8 Such specifications shall describe the implementation 

9 process from initial to final implementation phases, 

10 including how the Secretary will identify and notify 

11 potential enrollees and how and when beneficiaries 

12 may enroll and disenroll from Independence at 

13 Home programs and change the programs in which 

14 they are enrolled. 

15 ‘‘(8) PERIODIC PROGRESS REPORTS.—Semi-an16 nually during the first year in which this section is 

17 implemented and annually thereafter during the pe18 riod of implementation of this section, the Secretary 

19 shall submit to the Committees on Ways and Means 

20 and Energy and Commerce of the House of Rep21 resentatives and the Committee on Finance of the 

22 Senate a report that describes the progress of imple23 mentation of this section and explaining any vari24 ation from the Independence at Home program as 

25 described in this section. 


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1 ‘‘(9) ANNUAL BEST PRACTICES CONFERENCE.— 

2 During the initial implementation phase and to the 

3 extent practicable at intervals thereafter, the Sec4 retary shall provide for an annual Independence at 

5 Home teleconference for Independence at Home or6 ganizations to share best practices and review treat7 ment interventions and protocols that were success8 ful in meeting all 3 objectives specified in paragraph 

9 (1). 

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

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

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

13 grooming, transferring, feeding, or toileting. 

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

15 with respect to an individual with a qualifying func16 tional impairment, a family member, friend, or 

17 neighbor who provides assistance to the individual. 

18 ‘‘(3) ELIGIBLE BENEFICIARY.— 

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

20 beneficiary’ means, with respect to an Inde21 pendence at Home program, an individual 

22 who— 

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

24 A and enrolled under part B, but not en25 rolled in a plan under part C; 


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1 ‘‘(ii) has a qualifying functional im2 pairment and has been diagnosed with two 

3 or more of the chronic conditions described 

4 in subparagraph (C); and 

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

6 the individual first enrolling with an Inde7 pendence at Home program under this sec8 tion, has received benefits under part A for 

9 the following services: 

10 ‘‘(I) Non-elective inpatient hos11 pital services. 

12 ‘‘(II) Services in the emergency 

13 department of a hospital. 

14 ‘‘(III) Any one of the following: 

15 ‘‘(aa) Skilled nursing or sub16 acute rehabilitation services in a 

17 Medicare-certified nursing facil18 ity. 

19 ‘‘(bb) Comprehensive acute 

20 rehabilitation facility or Com21 prehensive outpatient rehabilita22 tion facility services. 

23 ‘‘(cc) Skilled nursing or re24 habilitation services through a 


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1 Medicare-certified home health 

2 agency. 

3 ‘‘(B) DISQUALIFICATIONS.—Such term 

4 does not include an individual— 

5 ‘‘(i) who is receiving benefits under 

6 section 1881; 

7 ‘‘(ii) who is enrolled in a PACE pro8 gram under section 1894; 

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

10 disenrolled from) a chronic care improve11 ment program under section 1807; 

12 ‘‘(iv) who within a 12-month period 

13 has been a resident for more than 90 days 

14 in a skilled nursing facility, a nursing facil15 ity (as defined in section 1919), or any 

16 other facility identified by the Secretary; 

17 ‘‘(v) who resides in a setting that pre18 sents a danger to the safety of in-home 

19 health care providers and primary care20 givers; or 

21 ‘‘(vi) whose enrollment in an Inde22 pendence at Home program the Secretary 

23 determines would be inappropriate. 


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1 ‘‘(C) CHRONIC CONDITIONS DESCRIBED.— 

2 The chronic conditions described in this sub3 paragraph are the following: 

4 ‘‘(i) Congestive heart failure. 

5 ‘‘(ii) Diabetes. 

6 ‘‘(iii) Chronic obstructive pulmonary 

7 disease. 

8 ‘‘(iv) Ischemic heart disease. 

9 ‘‘(v) Peripheral arterial disease. 

10 ‘‘(vi) Stroke. 

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

12 dementias designated by the Secretary. 

13 ‘‘(viii) Pressure ulcers. 

14 ‘‘(ix) Hypertension. 

15 ‘‘(x) Neurodegenerative diseases des16 ignated by the Secretary which result in 

17 high costs under this title, including 

18 amyotropic lateral sclerosis (ALS), mul19 tiple sclerosis, and Parkinson’s disease. 

20 ‘‘(xi) Any other chronic condition that 

21 the Secretary identifies as likely to result 

22 in high costs to the program under this 

23 title when such condition is present in 

24 combination with one or more of the 


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1 chronic conditions specified in the pre2 ceding clauses. 

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

4 The term ‘Independence at Home assessment’ 

5 means a determination of eligibility of an individual 

6 for an Independence at Home program as an eligible 

7 beneficiary (as defined in paragraph (3)), a com8 prehensive medical history, physical examination, 

9 and assessment of the beneficiary’s clinical and func10 tional status that— 

11 ‘‘(A) is conducted in person by an indi12 vidual— 

13 ‘‘(i) who— 

14 ‘‘(I) is an Independence at Home 

15 physician or an Independence at 

16 Home nurse practitioner; or 

17 ‘‘(II) a physician assistant, nurse 

18 practitioner, or clinical nurse spe19 cialist, as defined in section 

20 1861(aa)(5), who is employed by an 

21 Independence at Home organization 

22 and is supervised by an Independence 

23 at Home physician or Independence at 

24 Home nurse practitioner; and 


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1 ‘‘(ii) does not have an ownership in2 terest in the Independence at Home orga3 nization unless the Secretary determines 

4 that it is impracticable to preclude such in5 dividual’s involvement; and 

6 ‘‘(B) includes an assessment of— 

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

8 co-morbidities; 

9 ‘‘(ii) medications and medication ad10 herence; 

11 ‘‘(iii) affect, cognition, executive func12 tion, and presence of mental disorders; 

13 ‘‘(iv) functional status, including mo14 bility, balance, gait, risk of falling, and 

15 sensory function; 

16 ‘‘(v) social functioning and social inte17 gration; 

18 ‘‘(vi) environmental needs and a safe19 ty assessment; 

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

21 primary caregiver to assist with the bene22 ficiary’s care as well as the caregiver’s own 

23 physical and emotional capacity, education, 

24 and training; 


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1 ‘‘(viii) whether, in the professional 

2 judgment of the individual conducting the 

3 assessment, the beneficiary is likely to ben4 efit from an Independence at Home pro5 gram; 

6 ‘‘(ix) whether the conditions in the 

7 beneficiary’s home or place of residence 

8 would permit the safe provision of services 

9 in the home or residence, respectively, 

10 under an Independence at Home program; 

11 ‘‘(x) whether the beneficiary has a 

12 designated primary care physician whom 

13 the beneficiary has seen in an office-based 

14 setting within the previous 12 months; and 

15 ‘‘(xi) other factors determined appro16 priate by the Secretary. 

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

18 The term ‘Independence at Home care team’— 

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

20 a team of qualified individuals that provides 

21 services to the participant as part of an Inde22 pendence at Home program; and 

23 ‘‘(B) includes an Independence at Home 

24 physician or an Independence at Home nurse 

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1 ordinator (who may also be an Independence at 

2 Home physician or an Independence at Home 

3 nurse practitioner). 

4 ‘‘(6) INDEPENDENCE AT HOME COORDI5 NATOR.—The term ‘Independence at Home coordi6 nator’ means, with respect to a participant, an indi7 vidual who— 

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

9 Home organization and is responsible for co10 ordinating all of the services of the participant’s 

11 Independence at Home plan; 

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

13 as a physician, registered nurse, nurse practi14 tioner, clinical nurse specialist, physician assist15 ant, or other health care professional as the 

16 Secretary determines appropriate, who has at 

17 least one year of experience providing and co18 ordinating medical and related services for indi19 viduals in their homes; and 

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

21 responsible for communications with the partici22 pant and for facilitating communications with 

23 other health care providers under the plan. 

24 ‘‘(7) INDEPENDENCE AT HOME ORGANIZA25 TION.—The term ‘Independence at Home organizaVerDate Nov 24 2008 18:09 May 26, 2009 Jkt 079200 PO 00000 Frm 00021 Fmt 6652 Sfmt 6201 E:\BILLS\S1131.IS S1131

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1 tion’ means a provider of services, a physician or 

2 physician group practice, a nurse practitioner or 

3 nurse practitioner group practice which receives pay4 ment for services furnished under this title (other 

5 than only under this section) and which— 

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

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

8 Home program under this section; 

9 ‘‘(B)(i) provides all of the services of the 

10 Independence at Home plan in a participant’s 

11 home or place of residence, or 

12 ‘‘(ii) if the organization is not able to pro13 vide all such services in such home or residence, 

14 has adequate mechanisms for ensuring the pro15 vision of such services by one or more qualified 

16 entities; 

17 ‘‘(C) has Independence at Home physi18 cians, clinical nurse specialists, nurse practi19 tioners, or physician assistants available to re20 spond to patient emergencies 24 hours a day, 

21 seven days a week; 

22 ‘‘(D) accepts all eligible beneficiaries from 

23 the organization’s service area, as determined 

24 under the agreement with the Secretary under 


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1 this section, except to the extent that qualified 

2 staff are not available; and 

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

4 organization under this section. 

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

6 The term ‘Independence at Home physician’ means 

7 a physician who— 

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

9 Independence at Home organization, as re10 quired under paragraph (7)(C), or has another 

11 contractual relationship with the Independence 

12 at Home organization that requires the physi13 cian to make in-home visits and to be respon14 sible for the plans of care for the physician’s 

15 patients; 

16 ‘‘(B) is certified— 

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

18 Physicians, the American Board of Inter19 nal Medicine, the American Osteopathic 

20 Board of Family Physicians, the American 

21 Osteopathic Board of Internal Medicine, 

22 the American Board of Emergency Medi23 cine, or the American Board of Physical 

24 Medicine and Rehabilitation; or 


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

2 American Board of Medical Specialties and 

3 determined by the Secretary to be appro4 priate for the Independence at Home pro5 gram; 

6 ‘‘(C) has— 

7 ‘‘(i) a certification in geriatric medi8 cine as provided by American Board of 

9 Medical Specialties; or 

10 ‘‘(ii) passed the clinical competency 

11 examination of the American Academy of 

12 Home Care Physicians and has substantial 

13 experience in the delivery of medical care 

14 in the home, including at least two years 

15 of experience in the management of Medi16 care patients and one year of experience in 

17 home-based medical care including at least 

18 200 house calls; and 

19 ‘‘(D) has furnished services during the pre20 vious 12 months for which payment is made 

21 under this title. 

22 ‘‘(9) INDEPENDENCE AT HOME NURSE PRACTI23 TIONER.—The term ‘Independence at Home nurse 

24 practitioner’ means a nurse practitioner who— 


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

2 Independence at Home organization, as re3 quired under paragraph (7)(C), or has another 

4 contractual relationship with the Independence 

5 at Home organization that requires the nurse 

6 practitioner to make in-home visits and to be 

7 responsible for the plans of care for the nurse 

8 practitioner’s patients; 

9 ‘‘(B) practices in accordance with State 

10 law regarding scope of practice for nurse practi11 tioners; 

12 ‘‘(C) is certified— 

13 ‘‘(i) as a Gerontologic Nurse Practi14 tioner by the American Academy of Nurse 

15 Practitioners Certification Program or the 

16 American Nurses Credentialing Center; or 

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

18 adult nurse practitioner by the American 

19 Academy of Nurse Practitioners Certifi20 cation Board or the American Nurses 

21 Credentialing Center and holds a certifi22 cate of Added Qualification in gerontology, 

23 elder care or care of the older adult pro24 vided by the American Academy of Nurse 

25 Practitioners, the American Nurses 


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1 Credentialing Center or a national nurse 

2 practitioner certification board deemed by 

3 the Secretary to be appropriate for an 

4 Independence at Home program; and 

5 ‘‘(D) has furnished services during the pre6 vious 12 months for which payment is made 

7 under this title. 

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

9 term ‘Independence at Home plan’ means a plan es10 tablished under subsection (d)(2) for a specific par11 ticipant in an Independence at Home program. 

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

13 The term ‘Independence at Home program’ means a 

14 program described in subsection (d) that is operated 

15 by an Independence at Home organization. 

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

17 means an eligible beneficiary who has voluntarily en18 rolled in an Independence at Home program. 

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

20 entity’ means a person or organization that is li21 censed or otherwise legally permitted to provide the 

22 specific service (or services) provided under an Inde23 pendence at Home plan that the entity has agreed 

24 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 ‘‘(15) QUALIFIED INDIVIDUAL.—The term 

7 ‘qualified individual’ means a individual that is li8 censed or otherwise legally permitted to provide the 

9 specific service (or services) under an Independence 

10 at Home plan that the individual has agreed to pro11 vide. 

12 ‘‘(c) IDENTIFICATION AND ENROLLMENT OF PRO13 SPECTIVE PROGRAM PARTICIPANTS.— 

14 ‘‘(1) NOTICE TO ELIGIBLE INDEPENDENCE AT

15 HOME BENEFICIARIES.—The Secretary shall develop 

16 a model notice to be made available to Medicare 

17 beneficiaries (and to their caregivers) who are poten18 tially eligible for an Independence at Home program 

19 by participating providers and by Independence at 

20 Home programs. Such notice shall include the fol21 lowing information: 

22 ‘‘(A) A description of the potential advan23 tages to the beneficiary participating in an 

24 Independence at Home program. 


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1 ‘‘(B) A description of the eligibility re2 quirements to participate. 

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

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

5 benefits remain available to beneficiaries who 

6 enroll in an Independence at Home program. 

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

8 Independence at Home program will be respon9 sible for copayments for house calls made by 

10 Independence at Home physicians, physician as11 sistants, or by Independence at Home nurse 

12 practitioners, except that such copayments may 

13 be reduced or eliminated at the discretion of the 

14 Independence at Home physician, physician as15 sistant, or Independence at Home nurse practi16 tioner involved in accordance with subsection 

17 (f). 

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

19 could be provided. 

20 ‘‘(G) A description of the method for par21 ticipating, or withdrawing from participation, in 

22 an Independence at Home program or becoming 

23 no longer eligible to so participate. 

24 ‘‘(2) VOLUNTARY PARTICIPATION AND

25 CHOICE.—An eligible beneficiary may participate in 


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1 an Independence at Home program through enroll2 ment in such program on a voluntary basis and may 

3 terminate such participation at any time. Such a 

4 beneficiary may also receive Independence at Home 

5 services from the Independence at Home organiza6 tion of the beneficiary’s choice but may not receive 

7 Independence at Home services from more than one 

8 Independence at Home organization at a time. 

9 ‘‘(d) INDEPENDENCE AT HOME PROGRAM REQUIRE10 MENTS.— 

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

12 Home program shall, for each participant enrolled in 

13 the program— 

14 ‘‘(A) designate— 

15 ‘‘(i) an Independence at Home physi16 cian or an Independence at Home nurse 

17 practitioner; and 

18 ‘‘(ii) an Independence at Home coor19 dinator; 

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

21 participant received an Independence at Home 

22 assessment before enrollment in the program; 

23 ‘‘(C) with the participation of the partici24 pant (or the participant’s representative or 

25 caregiver), an Independence at Home physician, 


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1 a physician assistant under the supervision of 

2 an Independence at Home physician and as per3 mitted under State law, or an Independence at 

4 Home nurse practitioner, and the Independence 

5 at Home coordinator, develop an Independence 

6 at Home plan for the participant in accordance 

7 with paragraph (2); 

8 ‘‘(D) ensure that the participant receives 

9 an Independence at Home assessment at least 

10 every 6 months after the original assessment to 

11 ensure that the Independence at Home plan for 

12 the participant remains current and appro13 priate; 

14 ‘‘(E) implement all of the services under 

15 the participant’s Independence at Home plan 

16 and in instances in which the Independence at 

17 Home organization does not provide specific 

18 services within the Independence at Home plan, 

19 ensure that qualified entities successfully pro20 vide those specific services; and 

21 ‘‘(F) provide for an electronic medical 

22 record and electronic health information tech23 nology to coordinate the participant’s care and 

24 to exchange information with the Medicare pro25 gram and electronic monitoring and commuVerDate Nov 24 2008 18:09 May 26, 2009 Jkt 079200 PO 00000 Frm 00030 Fmt 6652 Sfmt 6201 E:\BILLS\S1131.IS S1131

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1 nication technologies and mobile diagnostic and 

2 therapeutic technologies as appropriate and ac3 cepted by the participant. 

4 ‘‘(2) INDEPENDENCE AT HOME PLAN.— 

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

6 Home plan for a participant shall be developed 

7 with the participant, an Independence at Home 

8 physician, a physician assistant under the su9 pervision of an Independence at Home physi10 cian and as permitted under State law, an Inde11 pendence at Home nurse practitioner, or an 

12 Independence at Home coordinator, and, if ap13 propriate, one or more of the participant’s care14 givers and shall— 

15 ‘‘(i) document the chronic conditions, 

16 co-morbidities, and other health needs 

17 identified in the participant’s Independence 

18 at Home assessment; 

19 ‘‘(ii) determine which services under 

20 an Independence at Home plan described 

21 in subparagraph (C) are appropriate for 

22 the participant; and 

23 ‘‘(iii) identify the qualified entity re24 sponsible for providing each service under 

25 such plan. 


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1 ‘‘(B) COMMUNICATION OF INDIVIDUALIZED

2 INDEPENDENCE AT HOME PLAN TO THE INDE3 PENDENCE AT HOME COORDINATOR.—If the in4 dividual responsible for conducting the partici5 pant’s Independence at Home assessment and 

6 developing the Independence at Home plan is 

7 not the participant’s Independence at Home co8 ordinator, the Independence at Home physician 

9 or Independence at Home nurse practitioner is 

10 responsible for ensuring that the participant’s 

11 Independence at Home coordinator has such 

12 plan and is familiar with the requirements of 

13 the plan and has the appropriate contact infor14 mation for all of the members of the Independ15 ence at Home care team. 

16 ‘‘(C) SERVICES PROVIDED UNDER AN

17 INDEPENDENCE AT HOME PLAN.—An Inde18 pendence at Home organization shall coordinate 

19 and make available through referral to a quali20 fied entity the services described in the fol21 lowing clauses (i) through (iii) to the extent 

22 they are needed and covered by under this title 

23 and shall provide the care coordination services 

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1 tent they are appropriate and accepted by a 

2 participant: 

3 ‘‘(i) Primary care services, such as 

4 physician visits, diagnosis, treatment, and 

5 preventive services. 

6 ‘‘(ii) Home health services, such as 

7 skilled nursing care and physical and occu8 pational therapy. 

9 ‘‘(iii) Phlebotomy and ancillary lab10 oratory and imaging services, including 

11 point of care laboratory and imaging 

12 diagnostics. 

13 ‘‘(iv) Care coordination services, con14 sisting of— 

15 ‘‘(I) Monitoring and management 

16 of medications by a pharmacist who is 

17 certified in geriatric pharmacy by the 

18 Commission for Certification in Geri19 atric Pharmacy or possesses other 

20 comparable certification dem21 onstrating knowledge and expertise in 

22 geriatric pharmacotherapy, as well as 

23 assistance to participants and their 

24 caregivers with respect to selection of 

25 a prescription drug plan under part D 


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•S 1131 IS

1 that best meets the needs of the par2 ticipant’s chronic conditions. 

3 ‘‘(II) Coordination of all medical 

4 treatment furnished to the partici5 pant, regardless of whether such 

6 treatment is covered and available to 

7 the participant under this title. 

8 ‘‘(III) Self-care education and 

9 preventive care consistent with the 

10 participant’s condition. 

11 ‘‘(IV) Education for primary 

12 caregivers and family members. 

13 ‘‘(V) Caregiver counseling serv14 ices and information about, and refer15 ral to, other caregiver support and 

16 health care services in the community. 

17 ‘‘(VI) Referral to social services, 

18 such as personal care, meals, volun19 teers, and individual and family ther20 apy. 

21 ‘‘(VII) Information about, and 

22 access to, hospice care. 

23 ‘‘(VIII) Pain and palliative care 

24 and end-of-life care, including infor25 mation about developing advanced diVerDate Nov 24 2008 18:09 May 26, 2009 Jkt 079200 PO 00000 Frm 00034 Fmt 6652 Sfmt 6201 E:\BILLS\S1131.IS S1131

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1 rectives and physicians orders for life 

2 sustaining treatment. 

3 ‘‘(3) PRIMARY TREATMENT ROLE WITHIN AN

4 INDEPENDENCE AT HOME CARE TEAM.—An Inde5 pendence at Home physician, a physician assistant 

6 under the supervision of an Independence at Home 

7 physician and as permitted under State law, or an 

8 Independence at Home nurse practitioner may as9 sume the primary treatment role as permitted under 

10 State law. 

11 ‘‘(4) ADDITIONAL RESPONSIBILITIES.— 

12 ‘‘(A) OUTCOMES REPORT.—Each Inde13 pendence at Home organization offering an 

14 Independence at Home program shall monitor 

15 and report to the Secretary, in a manner speci16 fied by the Secretary, on— 

17 ‘‘(i) patient outcomes; 

18 ‘‘(ii) beneficiary, caregiver, and pro19 vider satisfaction with respect to coordina20 tion of the participant’s care; and 

21 ‘‘(iii) the achievement of mandatory 

22 minimum savings described in subsection 

23 (e)(6). 

24 ‘‘(B) ADDITIONAL REQUIREMENTS.—Each 

25 such organization and program shall provide 


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•S 1131 IS

1 the Secretary with listings of individuals em2 ployed by the organization, including contract 

3 employees, and individuals with an ownership 

4 interest in the organization and comply with 

5 such additional requirements as the Secretary 

6 may specify. 

7 ‘‘(e) TERMS AND CONDITIONS.— 

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

9 section with an Independence at Home organization 

10 shall contain such terms and conditions as the Sec11 retary may specify consistent with this section. 

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

13 FINANCIAL REQUIREMENTS.—The Secretary may 

14 not enter into an agreement with such an organiza15 tion under this section for the operation of an Inde16 pendence at Home program unless— 

17 ‘‘(A) the program and organization meet 

18 the requirements of subsection (d), minimum 

19 quality and performance standards developed 

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

21 improvement, financial, program integrity, and 

22 other requirements as the Secretary deems to 

23 be appropriate for participants to be served; 

24 and 


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•S 1131 IS

1 ‘‘(B) the organization demonstrates to the 

2 satisfaction of the Secretary that the organiza3 tion is able to assume financial risk for per4 formance under the agreement with respect to 

5 payments made to the organization under such 

6 agreement through available reserves, reinsur7 ance, or withholding of funding provided under 

8 this title, or such other means as the Secretary 

9 determines appropriate. 

10 ‘‘(3) MINIMUM QUALITY AND PERFORMANCE

11 STANDARDS.— 

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

13 develop mandatory minimum quality and per14 formance standards for Independence at Home 

15 organizations and programs. 

16 ‘‘(B) STANDARDS TO BE INCLUDED.— 

17 Such standards shall include measures of— 

18 ‘‘(i) improvement in participant out19 comes; 

20 ‘‘(ii) improvement in satisfaction of 

21 the beneficiary, caregiver, and provider in22 volved; and 

23 ‘‘(iii) cost savings consistent with 

24 paragraph (6). 


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1 ‘‘(C) MINIMUM PARTICIPATION STAND2 ARD.—Such standards shall include a require3 ment that, for any year after the first year and 

4 except as the Secretary may provide for a pro5 gram serving a rural area, an Independence at 

6 Home program had an average number of par7 ticipants during the previous year of at least 

8 100 participants. 

9 ‘‘(4) TERM OF AGREEMENT AND MODIFICA10 TION.—The agreement under this subsection shall 

11 be, subject to paragraphs (3)(C) and (5), for a pe12 riod of three years, and the terms and conditions 

13 may be modified during the contract period by the 

14 Secretary as necessary to serve the best interest of 

15 the beneficiaries under this title or the best interest 

16 of Federal health care programs or upon the request 

17 of the Independence at Home organization. 

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

19 AGREEMENT.— 

20 ‘‘(A) IN GENERAL.—If the Secretary deter21 mines that an Independence at Home organiza22 tion has failed to meet the minimum perform23 ance standards under paragraph (3) or other 

24 requirements under this section, or if the Sec25 retary deems it necessary to serve the best inVerDate Nov 24 2008 18:09 May 26, 2009 Jkt 079200 PO 00000 Frm 00038 Fmt 6652 Sfmt 6201 E:\BILLS\S1131.IS S1131

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1 terest of the beneficiaries under this title or the 

2 best interest of Federal health care programs, 

3 the Secretary may terminate the agreement of 

4 the organization at the end of the contract year. 

5 ‘‘(B) REQUIRED TERMINATION WHERE

6 RISK TO HEALTH OR SAFETY OF A PARTICI7 PANT.—The Secretary shall terminate an agree8 ment with an Independence at Home organiza9 tion at any time the Secretary determines that 

10 the care being provided by such organization 

11 poses a threat to the health and safety of a par12 ticipant. 

13 ‘‘(C) TERMINATION BY INDEPENDENCE AT

14 HOME ORGANIZATIONS.—Notwithstanding any 

15 other provision of this subsection, an Independ16 ence at Home organization may terminate an 

17 agreement with the Secretary under this section 

18 to provide an Independence at Home program 

19 at the end of a contract year if the organization 

20 provides to the Secretary and to the bene21 ficiaries participating in the program notifica22 tion of such termination more than 90 days be23 fore the end of such year. Paragraphs (6), (8), 

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

25 the date of termination. 


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1 ‘‘(D) NOTICE OF INVOLUNTARY TERMI2 NATION.—The Secretary shall notify the par3 ticipants in an Independence at Home program 

4 as soon as practicable if a determination is 

5 made to terminate an agreement with the Inde6 pendence at Home organization involuntarily as 

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

8 notice shall inform the beneficiary of any other 

9 Independence at Home organizations that 

10 might be available to the beneficiary. 

11 ‘‘(6) MANDATORY MINIMUM SAVINGS.— 

12 ‘‘(A) REQUIRED.— 

13 ‘‘(i) IN GENERAL.—Under an agree14 ment under this subsection, each Inde15 pendence at Home organization shall en16 sure that during any year of the agreement 

17 for its Independence at Home program, 

18 there is an aggregate savings in the cost to 

19 the program under this title for partici20 pating beneficiaries, as calculated under 

21 subparagraph (B), that is not less than 5 

22 percent of the product described in clause 

23 (ii) for such participating beneficiaries and 

24 year. 


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1 ‘‘(ii) PRODUCT DESCRIBED.—The 

2 product described in this clause for partici3 pating beneficiaries in an Independence at 

4 Home program for a year is the product 

5 of— 

6 ‘‘(I) the estimated average 

7 monthly costs that would have been 

8 incurred under parts A and B (and, 

9 to the extent cost information is avail10 able, part D) if those beneficiaries had 

11 not participated in the Independence 

12 at Home program; and 

13 ‘‘(II) the number of participant14 months for that year. 

15 ‘‘(B) COMPUTATION OF AGGREGATE SAV16 INGS.— 

17 ‘‘(i) MODEL FOR CALCULATING SAV18 INGS.—The Secretary shall contract with a 

19 nongovernmental organization or academic 

20 institution to independently develop an an21 alytical model for determining whether an 

22 Independence at Home program achieves 

23 at least savings required under subpara24 graph (A) relative to costs that would have 

25 been incurred by Medicare in the absence 


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1 of Independence at Home programs. The 

2 analytical model developed by the inde3 pendent research organization for making 

4 these determinations shall utilize state-of5 the-art econometric techniques, such as 

6 Heckman’s selection correction methodolo7 gies, to account for sample selection bias, 

8 omitted variable bias, or problems with 

9 endogeneity. 

10 ‘‘(ii) APPLICATION OF THE MODEL.— 

11 Using the model developed under clause 

12 (i), the Secretary shall compare the actual 

13 costs to Medicare of beneficiaries partici14 pating in an Independence at Home pro15 gram to the predicted costs to Medicare of 

16 such beneficiaries to determine whether an 

17 Independence at Home program achieves 

18 the savings required under subparagraph 

19 (A). 

20 ‘‘(iii) REVISIONS OF THE MODEL.— 

21 The Secretary shall require that the model 

22 developed under clause (i) for determining 

23 savings shall be designed according to in24 structions that will control, or adjust for, 

25 inflation as well as risk factors including, 


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•S 1131 IS

1 age, race, gender, disability status, socio2 economic status, region of country (such as 

3 State, county, metropolitan statistical area, 

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

5 Secretary determines to be appropriate, in6 cluding adjustment for prior health care 

7 utilization. The Secretary may add to, 

8 modify, or substitute for such adjustment 

9 factors if such changes will improve the 

10 sensitivity or specificity of the calculation 

11 of costs savings. 

12 ‘‘(iv) PARTICIPANT-MONTH.—In mak13 ing the calculation described in subpara14 graph (A), each month or part of a month 

15 in a program year that a beneficiary par16 ticipates in an Independence at Home pro17 gram shall be counted as a ‘participant18 month’. 

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

20 No later than 30 days before the beginning of 

21 the first year of the pilot project under this sec22 tion and 120 days before the beginning of any 

23 Independence at Home program year after the 

24 first such year, the Secretary shall publish in 

25 the Federal Register a description of the model 


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•S 1131 IS

1 developed under subparagraph (B)(i) and infor2 mation for calculating savings required under 

3 subparagraph (A), including any revisions, suf4 ficient to permit Independence at Home organi5 zations to determine the savings they will be re6 quired to achieve during the program year to 

7 meet the savings requirement under subpara8 graph (A). In order to facilitate this notice, the 

9 Secretary may designate a single annual date 

10 for the beginning of all Independence at Home 

11 program years that shall not be later than one 

12 year from the date of enactment of this section. 

13 ‘‘(7) MANNER OF PAYMENT.—Subject to para14 graph (8), payments shall be made by the Secretary 

15 to an Independence at Home organization at a rate 

16 negotiated between the Secretary and the organiza17 tion under the agreement for— 

18 ‘‘(A) Independence at Home assessments; 

19 and 

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

21 for the items and services required to be pro22 vided or made available under subsection 

23 (d)(2)(C)(iv). 

24 ‘‘(8) ENSURING MANDATORY MINIMUM SAV25 INGS.—The Secretary shall require any IndependVerDate Nov 24 2008 18:09 May 26, 2009 Jkt 079200 PO 00000 Frm 00044 Fmt 6652 Sfmt 6201 E:\BILLS\S1131.IS S1131

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1 ence at Home organization that fails in any year to 

2 achieve the mandatory minimum savings described 

3 in paragraph (6) to provide those savings by refund4 ing payments made to the organization under para5 graph (7) during such year. 

6 ‘‘(9) BUDGET NEUTRAL PAYMENT CONDI7 TION.— 

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

9 the Secretary shall ensure that the cumulative, 

10 aggregate sum of Medicare program benefit ex11 penditures under parts A, B, and D for partici12 pants in Independence at Home programs and 

13 funds paid to Independence at Home organiza14 tions under this section, shall not exceed the 

15 Medicare program benefit expenditures under 

16 such parts that the Secretary estimates would 

17 have been made for such participants in the ab18 sence of such programs. 

19 ‘‘(B) TREATMENT OF SAVINGS.— 

20 ‘‘(i) INITIAL IMPLEMENTATION

21 PHASE.—If an Independence at Home or22 ganization achieves aggregate savings in a 

23 year in the initial implementation phase in 

24 excess of the mandatory minimum savings 

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1 cent of such aggregate savings shall be 

2 paid to the organization and the remainder 

3 shall be retained by the programs under 

4 this title during the initial implementation 

5 phase. 

6 ‘‘(ii) EXPANDED IMPLEMENTATION

7 PHASE.—If an Independence at Home or8 ganization achieves aggregate savings in a 

9 year in the expanded implementation phase 

10 in excess of 5 percent of the product de11 scribed in paragraph (6)(A)(ii)— 

12 ‘‘(I) insofar as such savings do 

13 not exceed 25 percent of such prod14 uct, 80 percent of such aggregate sav15 ings shall be paid to the organization 

16 and the remainder shall be retained 

17 by the programs under this title; and 

18 ‘‘(II) insofar as such savings ex19 ceed 25 percent of such product, in 

20 the Secretary’s discretion, 50 percent 

21 of such excess aggregate savings shall 

22 be paid to the organization and the 

23 remainder shall be retained by the 

24 programs under this title. 


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1 ‘‘(f) WAIVER OF COINSURANCE FOR HOUSE

2 CALLS.—A physician, physician assistant, or nurse practi3 tioner furnishing services related to the Independence at 

4 Home program in the home or residence of a participant 

5 in an Independence at Home program may waive collec6 tion of any coinsurance that might otherwise be payable 

7 under section 1833(a) with respect to such services but 

8 only if the conditions described in section 1128A(i)(6)(A) 

9 are met. 

10 ‘‘(g) REPORT.—Not later than three months after the 

11 date of receipt of the independent evaluation provided 

12 under subsection (a)(5) and each year thereafter during 

13 which this section is being implemented, the Secretary 

14 shall submit to the Committees of jurisdiction in Congress 

15 a report that shall include— 

16 ‘‘(1) whether the Independence at Home pro17 grams under this section are meeting the minimum 

18 quality and performance standards in (e)(3); 

19 ‘‘(2) a comparative evaluation of Independence 

20 at Home organizations in order to identify which 

21 programs, and characteristics of those programs, 

22 were the most effective in producing the best partici23 pant outcomes, patient and caregiver satisfaction, 

24 and cost savings; and 


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1 ‘‘(3) an evaluation of whether the participant 

2 eligibility criteria identified beneficiaries who were in 

3 the top ten percent of the highest cost Medicare 

4 beneficiaries.’’. 

5 (b) CONFORMING AMENDMENT.—Section 1833(a) of 

6 such Act (42 U.S.C. 1395l(a)) is amended, in the matter 

7 before paragraph (1), by inserting ‘‘and section 1807A(f)’’ 

8 after ‘‘section 1876’’. 

Æ 


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