II 

116TH CONGRESS 

1ST SESSION S. 1202 

To amend title XVIII of the Social Security Act to provide for a permanent 

Independence at Home medical practice program under the Medicare program. 

IN THE SENATE OF THE UNITED STATES 

APRIL 11, 2019 

Mr. MARKEY (for himself and Mr. PORTMAN) introduced the following bill; 

which was read twice and referred to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act to provide 

for a permanent Independence at Home medical practice 

program under the Medicare program. 

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

3 SECTION 1. SHORT TITLE. 

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

5 Act of 2019’’. 

6 SEC. 2. INDEPENDENCE AT HOME MEDICAL PRACTICE PRO7 GRAM. 

8 (a) PROGRAM.—Title XVIII of the Social Security 

9 Act is amended by inserting after section 1866F the fol10 lowing new section: 


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1 ‘‘INDEPENDENCE AT HOME MEDICAL PRACTICE PROGRAM

2 ‘‘SEC. 1866G. (a) ESTABLISHMENT.— 

3 ‘‘(1) IN GENERAL.—Not later than January 1, 

4 2021, the Secretary shall establish and implement a 

5 national independence at home medical practice pro6 gram (in this section referred to as the ‘Program’) 

7 that utilizes primary care teams that— 

8 ‘‘(A) are directed by physicians, nurse 

9 practitioners, or physician assistants; and 

10 ‘‘(B) emphasize home-based care that is 

11 designed to reduce expenditures and improve 

12 health outcomes in the provision of items and 

13 services under this title to applicable bene14 ficiaries. 

15 ‘‘(2) GOALS.—Under the Program, an inde16 pendence at home medical practice shall be account17 able for providing comprehensive, coordinated, con18 tinuous, and accessible care to applicable bene19 ficiaries at home and coordinating health care across 

20 all treatment settings, resulting in— 

21 ‘‘(A) reducing preventable hospitalizations; 

22 ‘‘(B) preventing hospital readmissions; 

23 ‘‘(C) reducing emergency room visits; 


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1 ‘‘(D) improving health outcomes commen2 surate with each applicable beneficiary’s stage 

3 of chronic illness; 

4 ‘‘(E) improving the efficiency of care, such 

5 as by reducing duplicative diagnostic and lab6 oratory tests; 

7 ‘‘(F) reducing the cost of items and serv8 ices covered under this title; and 

9 ‘‘(G) achieving applicable beneficiary and 

10 family caregiver satisfaction. 

11 ‘‘(b) INDEPENDENCE AT HOME MEDICAL PRAC12 TICE.— 

13 ‘‘(1) INDEPENDENCE AT HOME MEDICAL PRAC14 TICE DEFINED.—In this section: 

15 ‘‘(A) IN GENERAL.—The term ‘independ16 ence at home medical practice’ means a legal 

17 entity that meets each of the following require18 ments: 

19 ‘‘(i) The entity is comprised of an in20 dividual physician, nurse practitioner, or 

21 physician assistant or group of such practi22 tioners that furnishes care as part of a 

23 team that may include physicians, nurse 

24 practitioners, nurses, physician assistants, 

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1 tioners, social workers, and other health 

2 and social services staff, as appropriate. 

3 ‘‘(ii) The entity is organized, at least 

4 in part, for the purpose of furnishing phy5 sicians’ services. 

6 ‘‘(iii) The entity— 

7 ‘‘(I) has experience in furnishing 

8 home-based primary care services to 

9 applicable beneficiaries, as determined 

10 appropriate by the Secretary; 

11 ‘‘(II) makes in-home visits; and 

12 ‘‘(III) is available 24 hours per 

13 day, seven days per week, to carry out 

14 plans of care that are tailored to an 

15 applicable beneficiary’s chronic condi16 tions and designed to achieve the 

17 goals described in subparagraphs (A) 

18 through (G) of subsection (a)(2). 

19 ‘‘(iv) The entity enters into an agree20 ment with the Secretary. 

21 ‘‘(v) The entity furnishes services to 

22 at least 200 applicable beneficiaries during 

23 each year covered under the agreement un24 less the Secretary determines that a lower 

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1 ficiaries is necessary for the goals of the 

2 Program to be achieved. 

3 ‘‘(vi) The entity uses certified elec4 tronic health record technology and may 

5 use remote monitoring, mobile diagnostic 

6 technology, telehealth, and other commu7 nications-based technology services, as de8 termined appropriate by the Secretary. 

9 ‘‘(vii) The entity meets such other cri10 teria as the Secretary determines to be ap11 propriate to participate in the Program. 

12 ‘‘(B) PHYSICIAN.—The term ‘physician’ 

13 means a physician described in section 

14 1861(r)(1) who has the medical training or ex15 perience to fulfill the physician’s role described 

16 in subparagraph (A)(i). 

17 ‘‘(2) INCLUSION OF AFFILIATED PROVIDERS

18 AND PRACTITIONERS.—Nothing in this subsection 

19 shall prevent an independence at home medical prac20 tice from including providers of services, practi21 tioners described in section 1842(b)(18)(C), or other 

22 practitioners, including pharmacists, in an arrange23 ment with the practice to share in any savings under 

24 the Program. 


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1 ‘‘(c) QUALITY MEASURES AND PERFORMANCE

2 STANDARDS.— 

3 ‘‘(1) QUALITY MEASURES.— 

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

5 solicit stakeholder input and, taking into con6 sideration such input, determine appropriate 

7 quality measures to assess the quality of care 

8 furnished by independence at home medical 

9 practices. To the extent possible, such measures 

10 shall include outcome measures and experience 

11 of care measures. 

12 ‘‘(B) REPORTING REQUIREMENTS.—Under 

13 the Program, an independence at home medical 

14 practice shall submit data in a form and man15 ner and at a frequency specified by the Sec16 retary. 

17 ‘‘(2) QUALITY PERFORMANCE STANDARDS.— 

18 The Secretary shall establish quality performance 

19 standards that independence at home medical prac20 tices must meet in order to be eligible to receive in21 centive payments under subsection (d)(2). 

22 ‘‘(3) DATA SHARING.—Not less frequently than 

23 on a quarterly basis, the Secretary shall provide 

24 independence at home medical practices with regular 

25 practice-level feedback reports on cost and utilization 


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1 data in a clear and actionable manner. These reports 

2 shall include, to the extent practicable, information 

3 on fee-for-service cost and utilization, as well as ben4 eficiary-level lists of emergency department visits, 

5 hospitalizations, hierarchical condition category risk 

6 scores, quality performance data, claims line feed, 

7 and other high-cost services used in the previous 

8 quarter, together with other data that may be useful 

9 for practices, as determined by the Secretary. 

10 ‘‘(d) INCENTIVE PAYMENT METHODOLOGY.— 

11 ‘‘(1) ESTABLISHMENT OF TARGET SPENDING

12 LEVEL.—The Secretary shall establish an estimated 

13 annual spending target based on the amount the 

14 Secretary estimates would have been spent in the ab15 sence of the Program, for items and services covered 

16 under parts A and B furnished to applicable bene17 ficiaries or comparable beneficiaries, as determined 

18 by the Secretary, for each independence at home 

19 medical practice under this section. Such spending 

20 targets shall be determined on a per capita basis. 

21 Such spending targets shall include a risk corridor 

22 that takes into account normal variation in expendi23 tures for items and services covered under parts A 

24 and B furnished to such beneficiaries with the size 

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1 cable beneficiaries furnished services by each inde2 pendence at home medical practice. The spending 

3 targets may also be adjusted for applicable bene4 ficiary risk characteristics, factors relevant to char5 acterize random variation among practices, and 

6 other factors as the Secretary determines appro7 priate. 

8 ‘‘(2) INCENTIVE PAYMENTS.—Subject to meet9 ing the quality performance standards under sub10 section (c)(2), an independence at home medical 

11 practice is eligible to receive an incentive payment 

12 under the Program if actual expenditures for a year 

13 for the applicable beneficiaries who are attributed to 

14 the practice are less than the estimated spending 

15 target established under paragraph (1) for such 

16 year. An incentive payment for such year shall be 

17 equal to a portion (as determined by the Secretary 

18 but in no case greater than 80 percent) of the 

19 amount by which actual expenditures (including in20 centive payments under this paragraph) for applica21 ble beneficiaries under parts A and B for such year 

22 are estimated to be less than 5 percent less than the 

23 estimated spending target for such year, as deter24 mined under paragraph (1). 

25 ‘‘(e) APPLICABLE BENEFICIARY.— 


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1 ‘‘(1) IN GENERAL.—In this section, the term 

2 ‘applicable beneficiary’, with respect to an independ3 ence at home medical practice, is an individual who 

4 is attributed to such practice as a newly-assigned 

5 beneficiary or a continuously-assigned beneficiary 

6 (as such terms are defined in paragraphs (2) and 

7 (3), respectively). 

8 ‘‘(2) NEWLY-ASSIGNED BENEFICIARY DE9 FINED.—For purposes of paragraph (1), the term 

10 ‘newly-assigned beneficiary’ means an individual 

11 whom the independence at home medical practice 

12 has determined— 

13 ‘‘(A) is entitled to benefits under part A 

14 and enrolled for benefits under part B; 

15 ‘‘(B) is not— 

16 ‘‘(i) enrolled in a Medicare Advantage 

17 plan under part C or a PACE program 

18 under section 1894; 

19 ‘‘(ii) attributed under— 

20 ‘‘(I) another shared savings pro21 gram, under this title, such as under 

22 section 1899; or 

23 ‘‘(II) a model tested or expanded 

24 under section 1115A that involves 

25 shared savings under this title, or any 


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1 other demonstration that involves 

2 such shared savings; or 

3 ‘‘(iii) determined to have end stage 

4 renal disease as provided in section 226A 

5 or receiving dialysis at home; 

6 ‘‘(C) has two or more chronic illnesses, as 

7 determined by the Secretary, such as congestive 

8 heart failure, diabetes, chronic obstructive pul9 monary disease, ischemic heart disease, stroke, 

10 Alzheimer’s Disease and neurodegenerative dis11 eases, other dementias designated by the Sec12 retary, and other diseases and conditions which 

13 result in high costs under this title; 

14 ‘‘(D) subject to paragraph (4), during the 

15 12-month period immediately preceding the in16 dividual’s attribution to an independence at 

17 home medical practice— 

18 ‘‘(i) had a nonelective hospital admis19 sion; and 

20 ‘‘(ii) received— 

21 ‘‘(I) skilled nursing care or reha22 bilitation services in a skilled nursing 

23 facility paid under section 1888(e); 

24 ‘‘(II) rehabilitation services in an 

25 inpatient rehabilitation facility; or 


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1 ‘‘(III) part-time or intermittent 

2 nursing care (as described in section 

3 1861(m)(1)) through a home health 

4 agency or physical or occupational 

5 therapy or speech-language pathology 

6 services (as described in section 

7 1861(m)(2)) through a home health 

8 agency; 

9 ‘‘(E) has not been assigned to an inde10 pendence at home medical practice in a pre11 vious participation year during an agreement 

12 period; and 

13 ‘‘(F) meets such other criteria as the Sec14 retary determines appropriate. 

15 ‘‘(3) CONTINUOUSLY-ASSIGNED BENEFICIARY

16 DEFINED.—For purposes of paragraph (1), the term 

17 ‘continuously-assigned beneficiary’ means an indi18 vidual whom the independence at home medical 

19 practice has determined— 

20 ‘‘(A) meets the criteria described in sub21 paragraphs (A) through (C) and subparagraph 

22 (F) of paragraph (2); and 

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1 son (such as bathing, dressing, toileting, walk2 ing, or feeding). 

3 ‘‘(4) WAIVER OF CERTAIN REQUIREMENTS

4 WHEN BENEFICIARY CHANGES PLANS.—The require5 ments under paragraph (2)(D) shall not apply when 

6 an individual is attributed to an independence at 

7 home medical practice under this section subsequent 

8 to the first time an individual is attributed to such 

9 a practice under this section. 

10 ‘‘(5) PATIENT ELECTION TO PARTICIPATE.— 

11 The Secretary shall adopt an appropriate method to 

12 determine that applicable beneficiaries have agreed 

13 to enroll in an independence at home medical prac14 tice. Enrollment in an independence at home medical 

15 practice shall be voluntary. 

16 ‘‘(6) BENEFICIARY ACCESS TO SERVICES.— 

17 Nothing in this section shall be construed as— 

18 ‘‘(A) encouraging physicians, nurse practi19 tioners, physician assistants, or other team 

20 members to limit applicable beneficiary access 

21 to services covered under this title; or 

22 ‘‘(B) requiring applicable beneficiaries to 

23 relinquish access to any benefit under this title 

24 as a condition of receiving services from an 

25 independence at home medical practice. 


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1 ‘‘(f) AGREEMENTS.— 

2 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

3 an agreement with an independence at home medical 

4 practice under the Program shall be for a period de5 termined appropriate by the Secretary but in no case 

6 less than 3 years. 

7 ‘‘(2) RENEWALS.—Subject to subsection (j), the 

8 Secretary may renew an agreement with an inde9 pendence at home medical practice under the Pro10 gram. 

11 ‘‘(g) PERMITTING PRACTICES TO FURNISH SUPPLE12 MENTAL BENEFITS AT OWN EXPENSE.—Under the Pro13 gram, independence at home medical practices may fur14 nish applicable beneficiaries with items and services for 

15 which payment is not made under parts A and B, as deter16 mined by the Secretary. No payment for such items and 

17 services shall be made under this title. 

18 ‘‘(h) WAIVER AUTHORITY.— 

19 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

20 the Secretary may waive such provisions of this title 

21 and title XI as the Secretary determines necessary 

22 in order to implement the Program. 

23 ‘‘(2) LIMITATION.—The Secretary may only 

24 waive the collection of coinsurance that is payable by 

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1 tuary of the Centers for Medicare & Medicaid Serv2 ices certifies that such a waiver would reduce (or 

3 would not result in any increase in) net program 

4 spending under this title. 

5 ‘‘(i) ADMINISTRATION.—Chapter 35 of title 44, 

6 United States Code, shall not apply to this section. 

7 ‘‘(j) TERMINATION AND RE-ENTRY.— 

8 ‘‘(1) MANDATORY TERMINATION.—The Sec9 retary shall terminate an agreement with an inde10 pendence at home medical practice if— 

11 ‘‘(A) the Secretary determines that the 

12 practice did not achieve savings for the third of 

13 3 consecutive years under the Program; or 

14 ‘‘(B) such practice fails to meet at least a 

15 minimum number of quality performance stand16 ards established under subsection (c)(2) during 

17 any year of the agreement period. 

18 ‘‘(2) PERMISSIVE TERMINATION.—The Sec19 retary may terminate an agreement with an inde20 pendence at home medical practice for such other 

21 reasons determined appropriate by the Secretary. 

22 ‘‘(3) RE-ENTRY.—In the case where an inde23 pendence at home medical practice voluntarily elects 

24 to exit the Program during the demonstration phase 

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1 section (k)(1), the Secretary may re-enter into an 

2 agreement with such practice under this section if 

3 the Secretary determines that the practice would 

4 have otherwise met the requirements to remain in 

5 the Program under this section. 

6 ‘‘(k) PRACTICE TRANSITIONS.— 

7 ‘‘(1) PRACTICE MAKING TRANSITION FROM

8 DEMONSTRATION.—The Secretary shall provide for 

9 an appropriate transition from the demonstration 

10 program under section 1866E to the Program under 

11 this section. Such transition shall include a process 

12 that ensures that independence at home medical 

13 practices and applicable beneficiaries participating in 

14 such demonstration are automatically included in the 

15 Program under this section at the time of the imple16 mentation of the Program. 

17 ‘‘(2) PRACTICES NEWLY ENROLLING IN THE

18 PROGRAM.—The Secretary shall also provide for the 

19 participation of new medical practices in the Pro20 gram under this section, defined as practices that 

21 have not participated in the demonstration program 

22 under section 1866E previously, as well as practices 

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1 pating at the time of the implementation of the Pro2 gram under this section. 

3 ‘‘(3) SPECIAL RULE FOR INDIVIDUALS PARTICI4 PATING IN SIMILAR PROGRAMS.—In the case of an 

5 individual who has regularly received home-based 

6 primary care services, as determined by the Sec7 retary, during the 12-month period immediately pre8 ceding the individual’s attribution to an independ9 ence at home medical practice for the first time, the 

10 Secretary may, as determined appropriate, apply 

11 clause (i) of subsection (e)(2)(D) (relating to a prior 

12 nonelective hospital admission) by increasing the 12- 

13 month period described in such subsection as it re14 lates to such clause to a period of up to 24 months. 

15 ‘‘(l) LIMITATION ON REVIEW.—There shall be no ad16 ministrative or judicial review under section 1869, section 

17 1878, or otherwise of— 

18 ‘‘(1) the attribution of applicable beneficiaries 

19 to an independence at home medical practice; 

20 ‘‘(2) the determination of the estimated annual 

21 spending target for an independence at home med22 ical practice under subsection (d)(1); 

23 ‘‘(3) the assessment of the quality of care fur24 nished by an independence at home medical practice 


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1 and the establishment of quality performance stand2 ards under subsection (c); 

3 ‘‘(4) the determination of whether an independ4 ence at home medical practice is eligible for incen5 tive payments under subsection (d)(2), and the 

6 amount of such incentive payments; and 

7 ‘‘(5) the termination of an independence at 

8 home medical practice under subsection (j).’’. 

9 (b) GAO STUDY AND REPORT.— 

10 (1) STUDY.—The Comptroller General of the 

11 United States shall conduct a study on the inde12 pendence at home medical practice program under 

13 section 1866G of the Social Security Act, as added 

14 by subsection (a). Such study shall include an anal15 ysis of— 

16 (A) whether independence at home medical 

17 practices are meeting the requirements under 

18 such program; 

19 (B) whether such program is reducing ex20 penditures under this title; 

21 (C) the care that beneficiaries are receiving 

22 under such program; and 

23 (D) other areas determined appropriate by 

24 the Comptroller General. 


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1 (2) REPORT.—Not later than 5 years after the 

2 date of the implementation of such independence at 

3 home medical practice program, the Comptroller 

4 General of the United States shall submit to Con5 gress a report on the study conducted under para6 graph (1), together with such recommendations as 

7 the Comptroller General determines to be appro8 priate. 

9 (c) REVISIONS TO EXISTING DEMONSTRATION PRO10 GRAM.— 

11 (1) EXTENSION THROUGH THE IMPLEMENTA12 TION OF THE NEW PROGRAM.—Section 1866E(e)(1) 

13 of the Social Security Act (42 U.S.C. 1395cc– 

14 5(e)(1)) is amended by inserting ‘‘plus the period be15 ginning at the end of such 7-year period and ending 

16 on the date of the implementation of the Program 

17 under section 1866G’’ after ‘‘7-year period’’. 

18 (2) PERMITTING EXISTING PRACTICES TO SEE

19 MORE BENEFICIARIES.—Section 1866E(e)(5) of the 

20 Social Security Act (42 U.S.C. 1395cc–5(e)(1)) is 

21 amended— 

22 (A) in the second sentence, by inserting 

23 the following before the period: ‘‘plus for the 

24 period beginning at the end of such seventh 


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1 year and ending on the date of the implementa2 tion of the Program under section 1866G’’; and 

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

4 sentence: ‘‘Beginning on the date of the enact5 ment of this sentence, the limitation on the 

6 number of beneficiaries that may participate in 

7 the demonstration program pursuant to the 

8 first sentence shall not apply with respect to 

9 independence at home medical practices partici10 pating in the demonstration program as of such 

11 date of enactment.’’. 

Æ 


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