478 
fying ACOs under the pilot program at least annu-
ally. 
‘‘(4) LIMITATIONS ON REVIEW.—There shall be 
no administrative or judicial review under section 
1869, section 1878, or otherwise of— 
‘‘(A) the elements, parameters, scope, and 
duration of the pilot program; 
‘‘(B) the selection of qualifying ACOs for 
the pilot program; 
‘‘(C) the establishment of targets, measure-
ment of performance, determinations with re-
spect to whether savings have been achieved and 
the amount of savings; 
‘‘(D) determinations regarding whether, to 
whom, and in what amounts incentive payments 
are paid; and 
‘‘(E) decisions about the extension of the 
program under subsection (g), expansion of the 
program under subsection (h) or extensions 
under subsection (i). 
‘‘(5) ADMINISTRATION.—Chapter 35 of title 44, 
United States Code shall not apply to this section. 
‘‘(f) EVALUATION; MONITORING.— 
‘‘(1) IN GENERAL.—The Secretary shall evaluate 
the payment incentive model for each qualifying ACO 
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under the pilot program to assess impacts on bene-
ficiaries, providers of services, suppliers and the pro-
gram under this title. The Secretary shall make such 
evaluation publicly available within 60 days of the 
date of completion of such report. 
‘‘(2) MONITORING.—The Inspector General of the 
Department of Health and Human Services shall pro-
vide for monitoring of the operation of ACOs under 
the pilot program with regard to violations of section 
1877 (popularly known as the ‘Stark law’). 
‘‘(g) EXTENSION OF PILOT AGREEMENT WITH SUC-
CESSFUL ORGANIZATIONS.— 
‘‘(1) REPORTS TO CONGRESS.—Not later than 2 
years after the date the first agreement is entered into 
under this section, and biennially thereafter for six 
years, the Secretary shall submit to Congress and 
make publicly available a report on the use of au-
thorities under the pilot program. Each report shall 
address the impact of the use of those authorities on 
expenditures, access, and quality under this title. 
‘‘(2) EXTENSION.—Subject to the report provided 
under paragraph (1), with respect to a qualifying 
ACO, the Secretary may extend the duration of the 
agreement for such ACO under the pilot program as 
the Secretary determines appropriate if— 
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‘‘(A) the ACO receives incentive payments 
with respect to any of the first 4 years of the 
pilot agreement and is consistently meeting qual-
ity standards or 
‘‘(B) the ACO is consistently exceeding 
quality standards and is not increasing spend-
ing under the program. 
‘‘(3) TERMINATION.—The Secretary may termi-
nate an agreement with a qualifying ACO under the 
pilot program if such ACO did not receive incentive 
payments or consistently failed to meet quality stand-
ards in any of the first 3 years under the program. 
‘‘(h) EXPANSION TO ADDITIONAL ACOS.— 
‘‘(1) TESTING AND REFINEMENT OF PAYMENT IN-
CENTIVE
MODELS.—Subject to the evaluation de-
scribed in subsection (f), the Secretary may enter into 
agreements under the pilot program with additional 
qualifying ACOs to further test and refine payment 
incentive models with respect to qualifying ACOs. 
‘‘(2) EXPANDING USE OF SUCCESSFUL MODELS 
TO PROGRAM IMPLEMENTATION.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), the Secretary may issue regulations 
to implement, on a permanent basis, 1 or more 
models if, and to the extent that, such models are 
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beneficial to the program under this title, as de-
termined by the Secretary. 
‘‘(B) CERTIFICATION.—The Chief Actuary 
of the Centers for Medicare & Medicaid Services 
shall certify that 1 or more of such models de-
scribed in subparagraph (A) would result in esti-
mated spending that would be less than what 
spending would otherwise be estimated to be in 
the absence of such expansion. 
‘‘(i) TREATMENT
OF PHYSICIAN GROUP PRACTICE 
DEMONSTRATION.— 
‘‘(1) EXTENSION.—The Secretary may enter in 
to an agreement with a qualifying ACO under the 
demonstration under section 1866A, subject to re-
basing and other modifications deemed appropriate 
by the Secretary, until the pilot program under this 
section is operational. 
‘‘(2) TRANSITION.—For purposes of extension of 
an agreement with a qualifying ACO under sub-
section (g)(2), the Secretary shall treat receipt of an 
incentive payment for a year by an organization 
under the physician group practice demonstration 
pursuant to section 1866A as a year for which an in-
centive payment is made under such subsection, as 
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long as such practice group practice organization 
meets the criteria under subsection (b)(2). 
‘‘(j) ADDITIONAL PROVISIONS.— 
‘‘(1) AUTHORITY FOR SEPARATE INCENTIVE AR-
RANGEMENTS.—The Secretary may create separate 
incentive arrangements (including using multiple 
years of data, varying thresholds, varying shared sav-
ings amounts, and varying shared savings limits) for 
different categories of qualifying ACOs to reflect nat-
ural variations in data availability, variation in av-
erage annual attributable expenditures, program in-
tegrity, and other matters the Secretary deems appro-
priate. 
‘‘(2) ENCOURAGEMENT
OF
PARTICIPATION
OF 
SMALLER ORGANIZATIONS.—In order to encourage the 
participation of smaller accountable care organiza-
tions under the pilot program, the Secretary may 
limit a qualifying ACO’s exposure to high cost pa-
tients under the program. 
‘‘(3) TREATMENT OF HIGH-COST BENEFICIARIES 
WITH CHRONIC DISEASES.—Nothing in this section 
shall be construed as preventing a qualifying ACO 
from entering into an arrangement with an Inde-
pendence at Home Medical Practice or from pro-
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483 
viding home based services for the treatment of bene-
ficiaries who are eligible for that program. 
‘‘(4) INVOLVEMENT IN PRIVATE PAYER ARRANGE-
MENTS.—Nothing in this section shall be construed as 
preventing qualifying ACOs participating in the pilot 
program from negotiating similar contracts with pri-
vate payers. 
‘‘(5) 
ANTIDISCRIMINATION
LIMITATION.—The 
Secretary shall not enter into an agreement with an 
entity to provide health care items or services under 
the pilot program, or with an entity to administer the 
program, unless such entity guarantees that it will 
not deny, limit, or condition the coverage or provision 
of benefits under the program, for individuals eligible 
to be enrolled under such program, based on any 
health status-related factor described in section 
2702(a)(1) of the Public Health Service Act. 
‘‘(6) CONSTRUCTION.—Nothing in this section 
shall be construed to compel or require an organiza-
tion to use an organization-specific target growth rate 
for an accountable care organization under this sec-
tion for purposes of section 1848. 
‘‘(7) FUNDING.—For purposes of administering 
and carrying out the pilot program, other than for 
payments for items and services furnished under this 
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484 
title and incentive payments under subsection (c)(1), 
in addition to funds otherwise appropriated, there are 
appropriated to the Secretary for the Center for Medi-
care & Medicaid Services Program Management Ac-
count $25,000,000 for each of fiscal years 2010 
through 2014 and $20,000,000 for fiscal year 2015. 
Amounts appropriated under this paragraph for a 
fiscal year shall be available until expended.’’. 
SEC. 1302. MEDICAL HOME PILOT PROGRAM. 
(a) IN GENERAL.—Title XVIII of the Social Security 
Act is amended by inserting after section 1866E, as inserted 
by section 1301, the following new section: 
‘‘MEDICAL HOME PILOT PROGRAM 
‘‘SEC. 1866F. (a) ESTABLISHMENT
AND MEDICAL 
HOME MODELS.— 
‘‘(1) ESTABLISHMENT OF PILOT PROGRAM.—The 
Secretary shall establish a medical home pilot pro-
gram (in this section referred to as the ‘pilot pro-
gram’) for the purpose of evaluating the feasibility 
and advisability of reimbursing qualified patient-cen-
tered medical homes for furnishing medical home 
services (as defined under subsection (b)(1)) to high 
need beneficiaries (as defined in subsection (d)(1)(C)) 
and to targeted high need beneficiaries (as defined in 
subsection (c)(1)(C)). 
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‘‘(2) SCOPE.—Subject to subsection (g), the Sec-
retary shall set specific goals for the number of prac-
tices and communities, and the number of patients 
served, under the pilot program in the initial tests to 
ensure that the pilot program is of sufficient size and 
scope to— 
‘‘(A) test the approach involved in a variety 
of settings, including urban, rural, and under-
served areas; and 
‘‘(B) subject to subsection (e)(1), dissemi-
nate such approach rapidly on a national basis. 
To the extent that the Secretary finds a medical home 
model to be successful in improving quality and re-
ducing costs, the Secretary shall implement such 
mechanisms and reforms on as large a geographic 
scale as practical and economical. 
‘‘(3) MODELS OF MEDICAL HOMES IN THE PILOT 
PROGRAM.—The pilot program shall evaluate each of 
the following medical home models: 
‘‘(A) 
INDEPENDENT
PATIENT-CENTERED 
MEDICAL
HOME
MODEL.—Independent patient- 
centered medical home model under subsection 
(c). 
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‘‘(B) COMMUNITY-BASED
MEDICAL
HOME 
MODEL.—Community-based medical home model 
under subsection (d). 
‘‘(4) PARTICIPATION OF NURSE PRACTITIONERS 
AND PHYSICIAN ASSISTANTS.— 
‘‘(A) Nothing in this section shall be con-
strued as preventing a nurse practitioner from 
leading a patient centered medical home so long 
as— 
‘‘(i) all the requirements of this section 
are met; and 
‘‘(ii) the nurse practitioner is acting 
consistently with State law. 
‘‘(B) Nothing in this section shall be con-
strued as preventing a physician assistant from 
participating in a patient centered medical 
home so long as— 
‘‘(i) all the requirements of this section 
are met; and 
‘‘(ii) the physician assistant is acting 
consistently with State law. 
‘‘(b) DEFINITIONS.—For purposes of this section: 
‘‘(1) PATIENT-CENTERED MEDICAL HOME SERV-
ICES.—The term ‘patient-centered medical home serv-
ices’ means services that— 
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‘‘(A) provide beneficiaries with direct and 
ongoing access to a primary care or principal 
care by a physician or nurse practitioner who 
accepts responsibility for providing first contact, 
continuous and comprehensive care to such bene-
ficiary; 
‘‘(B) coordinate the care provided to a bene-
ficiary by a team of individuals at the practice 
level across office, institutional and home set-
tings led by a primary care or principal care 
physician or nurse practitioner, as needed and 
appropriate; 
‘‘(C) provide for all the patient’s health care 
needs or take responsibility for appropriately ar-
ranging care with other qualified providers for 
all stages of life; 
‘‘(D) provide continuous access to care and 
communication with participating beneficiaries; 
‘‘(E) provide support for patient self-man-
agement, proactive and regular patient moni-
toring, support for family caregivers, use pa-
tient-centered processes, and coordination with 
community resources; 
‘‘(F) integrate readily accessible, clinically 
useful information on participating patients 
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488 
that enables the practice to treat such patients 
comprehensively and systematically; and 
‘‘(G) implement evidence-based guidelines 
and apply such guidelines to the identified needs 
of beneficiaries over time and with the intensity 
needed by such beneficiaries. 
‘‘(2) PRIMARY CARE.—The term ‘primary care’ 
means health care that is provided by a physician, 
nurse practitioner, or physician assistant who prac-
tices in the field of family medicine, general internal 
medicine, geriatric medicine, or pediatric medicine. 
‘‘(3) PRINCIPAL
CARE.—The term ‘principal 
care’ means integrated, accessible health care that is 
provided by a physician who is a medical sub-
specialist that addresses the majority of the personal 
health care needs of patients with chronic conditions 
requiring the subspecialist’s expertise, and for whom 
the subspecialist assumes care management. 
‘‘(c) INDEPENDENT
PATIENT-CENTERED
MEDICAL 
HOME MODEL.— 
‘‘(1) IN GENERAL.— 
‘‘(A) PAYMENT
AUTHORITY.—Under the 
independent 
patient-centered 
medical 
home 
model under this subsection, the Secretary shall 
make payments for medical home services fur-
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nished by an independent patient-centered med-
ical home (as defined in subparagraph (B)) pur-
suant to paragraph (3)(B) for a targeted high 
need beneficiaries (as defined in subparagraph 
(C)). 
‘‘(B) 
INDEPENDENT
PATIENT-CENTERED 
MEDICAL HOME DEFINED.—In this section, the 
term 
‘independent 
patient-centered 
medical 
home’ means a physician-directed or nurse-prac-
titioner-directed practice that is qualified under 
paragraph (2) as— 
‘‘(i) providing beneficiaries with pa-
tient-centered medical home services; and 
‘‘(ii) meets such other requirements as 
the Secretary may specify. 
‘‘(C) TARGETED HIGH NEED BENEFICIARY 
DEFINED.—For purposes of this subsection, the 
term ‘targeted high need beneficiary’ means a 
high need beneficiary who, based on a risk score 
as specified by the Secretary, is generally within 
the upper 50th percentile of Medicare bene-
ficiaries. 
‘‘(D) BENEFICIARY ELECTION TO PARTICI-
PATE.—The Secretary shall determine an appro-
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priate method of ensuring that beneficiaries have 
agreed to participate in the pilot program. 
‘‘(E) IMPLEMENTATION.—The pilot pro-
gram under this subsection shall begin no later 
than 6 months after the date of the enactment of 
this section. 
‘‘(2) STANDARD
SETTING
AND
QUALIFICATION 
PROCESS
FOR
PATIENT-CENTERED
MEDICAL 
HOMES.—The Secretary shall review alternative mod-
els for standard setting and qualification, and shall 
establish a process— 
‘‘(A) to establish standards to enable med-
ical practices to qualify as patient-centered med-
ical homes; and 
‘‘(B) to initially provide for the review and 
certification of medical practices as meeting such 
standards. 
‘‘(3) PAYMENT.— 
‘‘(A) ESTABLISHMENT OF METHODOLOGY.— 
The Secretary shall establish a methodology for 
the payment for medical home services furnished 
by independent patient-centered medical homes. 
Under such methodology, the Secretary shall ad-
just payments to medical homes based on bene-
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491 
ficiary risk scores to ensure that higher pay-
ments are made for higher risk beneficiaries. 
‘‘(B) PER BENEFICIARY PER MONTH PAY-
MENTS.—Under such payment methodology, the 
Secretary shall pay independent patient-centered 
medical homes a monthly fee for each targeted 
high need beneficiary who consents to receive 
medical home services through such medical 
home. 
‘‘(C) 
PROSPECTIVE
PAYMENT.—The 
fee 
under subparagraph (B) shall be paid on a pro-
spective basis. 
‘‘(D) AMOUNT
OF
PAYMENT.—In deter-
mining the amount of such fee, the Secretary 
shall consider the following: 
‘‘(i) The clinical work and practice ex-
penses involved in providing the medical 
home services provided by the independent 
patient-centered medical home (such as pro-
viding increased access, care coordination, 
population disease management, and teach-
ing self-care skills for managing chronic ill-
nesses) for which payment is not made 
under this title as of the date of the enact-
ment of this section. 
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‘‘(ii) Allow for differential payments 
based on capabilities of the independent pa-
tient-centered medical home. 
‘‘(iii) Use appropriate risk-adjustment 
in determining the amount of the per bene-
ficiary per month payment under this 
paragraph in a manner that ensures that 
higher payments are made for higher risk 
beneficiaries. 
‘‘(4) ENCOURAGING PARTICIPATION OF VARIETY 
OF PRACTICES.—The pilot program under this sub-
section shall be designed to include the participation 
of physicians in practices with fewer than 10 full- 
time equivalent physicians, as well as physicians in 
larger practices, particularly in underserved and 
rural areas, as well as federally qualified community 
health centers, and rural health centers. 
‘‘(5) NO
DUPLICATION
IN
PILOT
PARTICIPA-
TION.—A physician in a group practice that partici-
pates in the accountable care organization pilot pro-
gram under section 1866D shall not be eligible to par-
ticipate in the pilot program under this subsection, 
unless the pilot program under this section has been 
implemented on a permanent basis under subsection 
(e)(3). 
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493 
‘‘(d) COMMUNITY-BASED MEDICAL HOME MODEL.— 
‘‘(1) IN GENERAL.— 
‘‘(A) AUTHORITY
FOR
PAYMENTS.—Under 
the community-based medical home model under 
this subsection (in this section referred to as the 
‘CBMH model’), the Secretary shall make pay-
ments for the furnishing of medical home services 
by a community-based medical home (as defined 
in subparagraph (B)) pursuant to paragraph 
(5)(B) for high need beneficiaries. 
‘‘(B) COMMUNITY-BASED
MEDICAL
HOME 
DEFINED.—In this section, the term ‘community- 
based medical home’ means a nonprofit commu-
nity-based or State-based organization that is 
certified under paragraph (2) as meeting the fol-
lowing requirements: 
‘‘(i) The organization provides bene-
ficiaries with medical home services. 
‘‘(ii) The organization provides med-
ical home services under the supervision of 
and in close collaboration with the primary 
care or principal care physician, nurse 
practitioner, or physician assistant des-
ignated by the beneficiary as his or her 
community-based medical home provider. 
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‘‘(iii) The organization employs com-
munity health workers, including nurses or 
other 
non-physician 
practitioners, 
lay 
health workers, or other persons as deter-
mined appropriate by the Secretary, that 
assist the primary or principal care physi-
cian, nurse practitioner, or physician as-
sistant in chronic care management activi-
ties such as teaching self-care skills for 
managing chronic illnesses, transitional 
care services, care plan setting, medication 
therapy management services for patients 
with multiple chronic diseases, or help bene-
ficiaries access the health care and commu-
nity-based resources in their local geo-
graphic area. 
‘‘(iv) The organization meets such 
other requirements as the Secretary may 
specify. 
‘‘(C) HIGH
NEED
BENEFICIARY.—In this 
section, the term ‘high need beneficiary’ means 
an individual who requires regular medical 
monitoring, advising, or treatment, including 
such an individual with cognitive impairment 
that leads to functional impairment. 
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495 
‘‘(2) QUALIFICATION PROCESS FOR COMMUNITY- 
BASED MEDICAL HOMES.—The Secretary shall estab-
lish a process— 
‘‘(A) for the initial qualification of commu-
nity-based or State-based organizations as com-
munity-based medical homes; and 
‘‘(B) to provide for the review and quali-
fication of such community-based and State- 
based organizations pursuant to criteria estab-
lished by the Secretary. 
‘‘(3) DURATION.—The pilot program for commu-
nity-based medical homes under this subsection shall 
start no later than 2 years after the date of the enact-
ment of this section. Each demonstration site under 
the pilot program shall operate for a period of up to 
5 years after the initial implementation phase, with-
out regard to the receipt of a initial implementation 
funding under subsection (i). 
‘‘(4) PREFERENCE.—In selecting sites for the 
CBMH model, the Secretary shall seek to eliminate 
racial, ethnic, gender, and geographic health dispari-
ties and may give preference to— 
‘‘(A) applications from geographic areas 
that propose to coordinate health care services for 
chronically ill beneficiaries across a variety of 
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496 
health care settings, such as primary care physi-
cian practices with fewer than 10 physicians, 
specialty physicians, nurse practitioner prac-
tices, Federally qualified health centers, rural 
health clinics, and other settings; 
‘‘(B) applications that include other payors 
that furnish medical home services for chron-
ically ill patients covered by such payors; and 
‘‘(C) applications from States that propose 
to use the medical home model to coordinate 
health care services for individuals enrolled 
under this title, individuals enrolled under title 
XIX, and full-benefit dual eligible individuals 
(as defined in section 1935(c)(6)) with chronic 
diseases across a variety of health care settings. 
‘‘(5) PAYMENTS.— 
‘‘(A) ESTABLISHMENT OF METHODOLOGY.— 
The Secretary shall establish a methodology for 
the payment for medical home services furnished 
under the CBMH model. 
‘‘(B) PER BENEFICIARY PER MONTH PAY-
MENTS.—Under such payment methodology, the 
Secretary shall make two separate monthly pay-
ments for each high need beneficiary who con-
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sents to receive medical home services through 
such medical home, as follows: 
‘‘(i) PAYMENT
TO
COMMUNITY-BASED 
ORGANIZATION.—One monthly payment to 
a community-based or State-based organiza-
tion. 
‘‘(ii) PAYMENT TO PRIMARY OR PRIN-
CIPAL CARE PRACTICE.—One monthly pay-
ment to the primary or principal care prac-
tice for such beneficiary. 
‘‘(C) PROSPECTIVE
PAYMENT.—The pay-
ments under subparagraph (B) shall be paid on 
a prospective basis. 
‘‘(D) AMOUNT
OF
PAYMENT.—In deter-
mining the amount of such payment, the Sec-
retary shall consider the following: 
‘‘(i) The clinical work and practice ex-
penses involved in providing the medical 
home services provided by the community- 
based medical home (such as providing in-
creased access, care coordination, care plan 
setting, population disease management, 
and teaching self-care skills for managing 
chronic illnesses) for which payment is not 
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498 
made under this title as of the date of the 
enactment of this section. 
‘‘(ii) Use appropriate risk-adjustment 
in determining the amount of the per bene-
ficiary per month payment under this 
paragraph. 
‘‘(6) INITIAL
IMPLEMENTATION
FUNDING.—The 
Secretary may make available initial implementation 
funding to a community based or State-based organi-
zation or a State that is participating in the pilot 
program under this subsection. Such organization 
shall provide the Secretary with a detailed implemen-
tation plan that includes how such funds will be used. 
The Secretary shall select a territory of the United 
States as one of the locations in which to implement 
the pilot program under this subsection. 
‘‘(e) EXPANSION OF PROGRAM.— 
‘‘(1) EVALUATION OF COST AND QUALITY.—The 
Secretary shall evaluate the pilot program to deter-
mine— 
‘‘(A) the extent to which medical homes re-
sult in— 
‘‘(i) improvement in the quality and 
coordination of health care services, particu-
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larly with regard to the care of complex pa-
tients; 
‘‘(ii) improvement in reducing health 
disparities; 
‘‘(iii) reductions in preventable hos-
pitalizations; 
‘‘(iv) prevention of readmissions; 
‘‘(v) reductions in emergency room vis-
its; 
‘‘(vi) improvement in health outcomes, 
including patient functional status where 
applicable; 
‘‘(vii) improvement in patient satisfac-
tion; 
‘‘(viii) improved efficiency of care such 
as reducing duplicative diagnostic tests and 
laboratory tests; and 
‘‘(ix) reductions in health care expend-
itures; and 
‘‘(B) the feasability and advisability of re-
imbursing medical homes for medical home serv-
ices under this title on a permanent basis. 
‘‘(2) REPORT.—Not later than 60 days after the 
date of completion of the evaluation under paragraph 
(1), the Secretary shall submit to Congress and make 
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available to the public a report on the findings of the 
evaluation under paragraph (1). 
‘‘(3) EXPANSION OF PROGRAM.— 
‘‘(A) IN GENERAL.—Subject to the results of 
the evaluation under paragraph (1) and sub-
paragraph (B), the Secretary may issue regula-
tions to implement, on a permanent basis, one or 
more models, if, and to the extent that such 
model or models, are beneficial to the program 
under this title, including that such implementa-
tion will improve quality of care, as determined 
by the Secretary. 
‘‘(B) CERTIFICATION
REQUIREMENT.—The 
Secretary may not issue such regulations unless 
the Chief Actuary of the Centers for Medicare & 
Medicaid Services certifies that the expansion of 
the components of the pilot program described in 
subparagraph (A) would result in estimated 
spending under this title that would be no more 
than the level of spending that the Secretary esti-
mates would otherwise be spent under this title 
in the absence of such expansion. 
‘‘(f) ADMINISTRATIVE PROVISIONS.— 
‘‘(1) NO
DUPLICATION
IN
PAYMENTS.—During 
any month, the Secretary may not make payments 
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under this section under more than one model or 
through more than one medical home under any 
model for the furnishing of medical home services to 
an individual. 
‘‘(2) NO EFFECT ON PAYMENT FOR EVALUATION 
AND MANAGEMENT SERVICES.—Payments made under 
this section are in addition to, and have no effect on 
the amount of, payment for evaluation and manage-
ment services made under this title 
‘‘(3) ADMINISTRATION.—Chapter 35 of title 44, 
United States Code shall not apply to this section. 
‘‘(g) FUNDING.— 
‘‘(1) OPERATIONAL COSTS.—For purposes of ad-
ministering and carrying out the pilot program (in-
cluding the design, implementation, technical assist-
ance for and evaluation of such program), in addition 
to funds otherwise available, there shall be transferred 
from the Federal Supplementary Medical Insurance 
Trust Fund under section 1841 to the Secretary for 
the Centers for Medicare & Medicaid Services Pro-
gram Management Account $6,000,000 for each of fis-
cal years 2010 through 2014. Amounts appropriated 
under this paragraph for a fiscal year shall be avail-
able until expended. 
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502 
‘‘(2) PATIENT-CENTERED MEDICAL HOME SERV-
ICES.—In addition to funds otherwise available, there 
shall be available to the Secretary for the Centers for 
Medicare & Medicaid Services, from the Federal Sup-
plementary Medical Insurance Trust Fund under sec-
tion 1841— 
‘‘(A) $200,000,000 for each of fiscal years 
2010 through 2014 for payments for medical 
home services under subsection (c)(3); and 
‘‘(B) $125,000,000 for each of fiscal years 
2012 through 2016, for payments under sub-
section (d)(5). 
Amounts available under this paragraph for a fiscal 
year shall be available until expended. 
‘‘(3) INITIAL IMPLEMENTATION.—In addition to 
funds otherwise available, there shall be available to 
the Secretary for the Centers for Medicare & Medicaid 
Services, from the Federal Supplementary Medical 
Insurance Trust Fund under section 1841, $2,500,000 
for each of fiscal years 2010 through 2012, under sub-
section (d)(6). Amounts available under this para-
graph for a fiscal year shall be available until ex-
pended. 
‘‘(h) TREATMENT OF TRHCA MEDICARE MEDICAL 
HOME DEMONSTRATION FUNDING.— 
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‘‘(1) In addition to funds otherwise available for 
payment of medical home services under subsection 
(c)(3), there shall also be available the amount pro-
vided in subsection (g) of section 204 of division B 
of the Tax Relief and Health Care Act of 2006 (42 
U.S.C. 1395b–1 note). 
‘‘(2) Notwithstanding section 1302(c) of the 
America’s Affordable Health Choices Act of 2009, in 
addition to funds provided in paragraph (1) and sub-
section (g)(2)(A), the funding for medical home serv-
ices that would otherwise have been available if such 
section 204 medical home demonstration had been im-
plemented (without regard to subsection (g) of such 
section) shall be available to the independent patient- 
centered medical home model described in subsection 
(c).’’. 
(b) EFFECTIVE DATE.—The amendment made by this 
section shall apply to services furnished on or after the date 
of the enactment of this Act. 
(c) CONFORMING REPEAL.—Section 204 of division B 
of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 
1395b–1 note), as amended by section 133(a)(2) of the 
Medicare Improvements for Patients and Providers Act of 
2008 (Public Law 110–275), is repealed. 
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504 
SEC. 1303. INDEPENDENCE AT HOME PILOT PROGRAM. 
Title XVIII of the Social Security Act is amended by 
inserting after section 1866F, as inserted by section 1302, 
the following new section: 
‘‘INDEPENDENCE AT HOME MEDICAL PRACTICE PILOT 
PROGRAM 
‘‘SEC. 1866G. (a) IN GENERAL.—The Secretary shall 
conduct a pilot program (in this section referred to as the 
‘pilot program’) to test a payment incentive and service de-
livery model that utilizes physician and nurse practitioner 
directed home-based primary care teams designed to reduce 
expenditures and improve health outcomes in the provision 
of items and services under this title to applicable bene-
ficiaries (as defined in subsection (d)). The pilot program 
tests whether such a model, which is accountable for pro-
viding comprehensive, coordinated, continuous, and acces-
sible care to high-need populations at home and coordi-
nating health care across all treatment settings, results in— 
‘‘(1) reducing preventable hospitalizations; 
‘‘(2) preventing hospital readmissions; 
‘‘(3) reducing emergency room visits; 
‘‘(4) improving health outcomes; 
‘‘(5) improving the efficiency of care, such as by 
reducing duplicative diagnostic and laboratory tests; 
‘‘(6) reducing the cost of health care services cov-
ered under this title; and 
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‘‘(7) achieving beneficiary and family caregiver 
satisfaction. 
‘‘(b) QUALIFYING INDEPENDENCE AT HOME MEDICAL 
PRACTICE.— 
‘‘(1) DEFINITION.—In this section, the term 
‘qualifying independence at home medical practice’ 
means a legal entity comprised of an individual phy-
sician or nurse practitioner or group of physicians 
and nurse practitioners who are certified or have ex-
perience and training in providing home-based pri-
mary care services to high cost chronically ill bene-
ficiaries as determined appropriate by the Secretary 
and which has entered into an agreement with the 
Secretary. Care is provided by a team, including phy-
sicians, nurses, physician assistants, pharmacists, 
and other health and social services staff as appro-
priate who are certified or have experience providing 
home-based primary care to applicable beneficiaries, 
make in-home visits and carry out plans of care that 
are tailored to the individual beneficiary’s chronic 
conditions and designed to achieve the results in sub-
section (a) and report the clinical and quality of care 
outcomes as determined by the Secretary. The pilot 
program shall be designed to include the participa-
tion of physician and nurse practitioner practices 
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506 
with fewer than 10 full-time equivalent physicians, as 
well as physicians in larger practices, particularly in 
underserved rural areas. 
‘‘(2) PARTICIPATION OF NURSE PRACTITIONERS 
AND PHYSICIAN ASSISTANTS.—Nothing in this section 
shall be construed to prevent a nurse practitioner or 
physician assistant from leading a home-based pri-
mary care team as part of an Independence at Home 
Medical Practice if— 
‘‘(A) all the requirements of this section are 
met; and 
‘‘(B) the nurse practitioner or physician as-
sistant, as the case may be, is acting consistently 
with State law. 
‘‘(3) INCLUSION
OF
PROVIDERS
AND
PRACTI-
TIONERS.—Nothing in this subsection shall be con-
strued as preventing a qualifying Independence at 
Home Medical Practice from including a provider or 
participating practitioner that is affiliated with the 
medical practice under an arrangement structured so 
that such provider or practitioner participates in the 
pilot program and shares in any savings under the 
pilot program. 
‘‘(c) PAYMENT.— 
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507 
‘‘(1) SHARED SAVINGS.—A qualifying Independ-
ence at Home Medical Practice may receive 80 per-
cent of savings in excess of 5 percent if expenditures 
under this title for applicable beneficiaries partici-
pating in the pilot program are at least 5 percent less 
than a target spending level or a target rate of 
growth. The shared savings payment shall be made 
only if savings are at a minimum 5 percent greater 
than would result from normal variation in expendi-
tures for items and services covered under parts A 
and B (and part D to the extent the Secretary decides 
to include such costs). 
‘‘(2) ESTABLISHMENT OF LEVELS, THRESHOLDS, 
AND
LIMITS.—The Secretary may establish target 
spending levels, savings thresholds, and limits on 
shared savings amounts for each participating Inde-
pendence at Home Medical Practice based upon the 
size of the practice, characteristics of the enrolled in-
dividuals, and such other factors as the Secretary de-
termines appropriate. 
‘‘(3) INTERIM
PAYMENTS.—A qualifying Inde-
pendence at Home Medical Practice may receive pay-
ments for geriatric assessments and monthly care co-
ordination services as determined by the Secretary 
but in the event that an Independence at Home Med-
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508 
ical Practice does not achieve the required savings in 
this subsection, those payments or a fraction of them, 
as appropriate, are at risk of being recouped by the 
Secretary to ensure that no Independence at Home 
Medical Practice receives Medicare payments in ex-
cess of what Medicare otherwise would have paid for 
the services provided to the beneficiaries receiving 
medical care from the Independence at Home Medical 
Practice in the absence of the pilot program. 
‘‘(4) ASSURANCE OF FINANCIAL SOLVENCY.—In 
order to receive payments under paragraph (3), a 
qualifying Independence at Home Medical Practice 
shall demonstrate to the satisfaction of the Secretary 
that the organization is able to assume financial risk 
for the 5 percent savings requirements through avail-
able reserves, reinsurance, or withholding of funding 
provided under this title, or such other means as the 
Secretary determines appropriate. 
‘‘(5) 
NO
ADDITIONAL
PROGRAM
EXPENDI-
TURES.—The Secretary shall limit shared savings 
payments to each qualifying Independence at Home 
Medical Practice under this subsection as necessary to 
ensure that the aggregate expenditures with respect to 
applicable beneficiaries for such Independence at 
Home Medical Practice under this title (inclusive of 
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509 
shared savings payments described in this paragraph) 
do not exceed the amount that the Secretary estimates 
would be expended for such Independence at Home 
Medical Practice for such beneficiaries if the pilot 
program under this section were not implemented. 
‘‘(d) APPLICABLE BENEFICIARIES.— 
‘‘(1) DEFINITION.—In this section, the term ‘ap-
plicable beneficiary’ means, with respect to a quali-
fying Independence at Home Medical Practice, an in-
dividual who— 
‘‘(A) is enrolled under part B and entitled 
to benefits under part A; 
‘‘(B) is not enrolled in a Medicare Advan-
tage plan under part C or a PACE program 
under section 1894; 
‘‘(C) is in the top 20 percent of Medicare 
patient risk scores; 
‘‘(D) has two or more chronic illnesses, in-
cluding congestive heart failure, diabetes, chronic 
obstructive pulmonary disease, ischemic heart 
disease, stroke, Alzheimer’s Disease and other de-
mentias designated by the Secretary, pressure ul-
cers, hypertension, neurodegenerative diseases 
designated by the Secretary which result in high 
costs under this title including amyotropic lat-
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510 
eral sclerosis (ALS), multiple sclerosis, and Par-
kinson’s disease, and other chronic conditions 
identified by the Secretary that result in high 
costs when in combination with one or more of 
the diseases listed in this subparagraph; 
‘‘(E) had a nonelective hospital admission 
within the past 12 months; 
‘‘(F) has received acute or subacute rehabili-
tation services; 
‘‘(G) continues to have two or more func-
tional dependencies requiring the assistance of 
another person (for example, bathing, dressing, 
toileting, walking, or feeding); and 
‘‘(H) fulfills such other criteria as the Sec-
retary determines appropriate. 
‘‘(2) PUBLICATION
OF
REQUIREMENTS.—The 
Secretary shall publish eligibility requirements for 
beneficiaries that are sufficiently clear to be under-
stood by beneficiaries and the individuals providing 
services to them as part of the pilot program. 
‘‘(3) PATIENT ELECTION TO PARTICIPATE.—The 
Secretary shall determine an appropriate method of 
ensuring that applicable beneficiaries have agreed to 
participate in an Independence at Home Medical 
Practice. Participation shall be entirely voluntary. 
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511 
‘‘(4) BENEFICIARY ACCESS TO SERVICES.—Ex-
cept as provided in subsection (e)(2), nothing in this 
section shall be construed as encouraging physicians 
or nurse practitioners to limit beneficiary access to 
services covered under title XVIII and beneficiaries 
shall not be required to relinquish access to any ben-
efit under this title as a condition of receiving serv-
ices from an Independence at Home Medical Practice. 
‘‘(e) IMPLEMENTATION.— 
‘‘(1) STARTING DATE.—The pilot program shall 
begin not later than January 1, 2012. An agreement 
with a qualifying Independence at Home Medical 
Practice under the pilot program may cover a 3 year 
period. 
‘‘(2) NO
DUPLICATION
IN
PILOT
PARTICIPA-
TION.—A physician or nurse practitioner who par-
ticipates in the accountable care organization pilot 
program under section 1866D or the medical home 
pilot program under section 1866E shall not be eligi-
ble to participate in the pilot program under this 
subsection. 
‘‘(3) PREFERENCE.—In approving an Independ-
ence at Home Medical Practice, the Secretary shall 
give preference to medical practices that are— 
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512 
‘‘(A) located in high cost areas of the coun-
try; 
‘‘(B) have experience in furnishing health 
care services to applicable beneficiaries in the 
home; and 
‘‘(C) use electronic medical records, health 
information 
technology, 
and 
individualized 
plans of care. 
‘‘(4) WAIVER.—The Secretary may waive such 
provisions of this title (including section 1877) and 
title XI in the manner the Secretary determines nec-
essary in order implement the pilot program. 
‘‘(5) ADMINISTRATION.—Chapter 35 of title 44, 
United States Code shall not apply to this section. 
‘‘(f) MINIMUM NUMBER
OF SITES.—To the extent 
practicable, at least two unaffiliated Independence at Home 
Medical Practices will be established in the 13 highest cost 
States and the District of Columbia and in 13 additional 
States that are representative of other regions of the United 
States and include medically underserved rural and urban 
areas as determined by the Secretary. 
‘‘(g) EVALUATION AND MONITORING.—The Secretary 
shall annually evaluate each qualifying Independence at 
Home Medical Practice under the pilot program to assess 
whether it achieved the minimum savings of 5 percent and 
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513 
the results described in subsection (a). The Secretary shall 
have the discretion to terminate an agreement with an Inde-
pendence at Home Medical Practice that fails to achieve 
a preponderance of those results. The Secretary shall make 
evaluations publicly available within 60 days of the date 
of completion of such report. 
‘‘(h) REPORTS TO CONGRESS.—Not later than 2 years 
after the date the first agreement is entered into under this 
section, and biennially thereafter until the pilot is com-
pleted, the Secretary shall submit to Congress and make 
publicly available a report on best practices under the pilot 
program. Each report shall address the impact of such best 
practices on expenditures, access, and quality under this 
title. 
‘‘(i) EXPANSION TO PROGRAM IMPLEMENTATIONS.— 
‘‘(1) TESTING AND REFINEMENT OF PAYMENT IN-
CENTIVE AND SERVICE DELIVERY MODELS.—Subject 
to the evaluation described in subsection (f), the Sec-
retary may enter into agreements under the pilot pro-
gram with additional qualifying Independence at 
Home Medical Practices to further test and refine 
models with respect to qualifying Independence at 
Home Medical Practices. 
‘‘(2) EXPANDING USE OF SUCCESSFUL MODELS 
TO PROGRAM IMPLEMENTATION.— 
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514 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), the Secretary may issue regulations 
to implement, on a permanent basis, the Inde-
pendence at Home Medical Practice Model if, 
and to the extent that, such models are beneficial 
to the program under this title, as determined by 
the Secretary. 
‘‘(B) CERTIFICATION.—The Chief Actuary 
of the Centers for Medicare and Medicaid Serv-
ices shall certify that the Independence at Home 
Medical Model described in subparagraph (A) 
would result in estimated spending that would be 
less than what spending would otherwise be esti-
mated to be in the absence of such expansion. 
‘‘(j) FUNDING.—For purposes of administering and 
carrying out the pilot program, other than for payments 
for items and services furnished under this title, shared sav-
ings and monthly fees, or other payments under subsection 
(c), in addition to funds otherwise appropriated, there are 
appropriated to the Secretary for the Center for Medicare 
and Medicaid Services Program Management Account 
$5,000,000 for each of fiscal years 2010 through 2014. 
Amounts appropriated under this paragraph for a fiscal 
year shall be available until expended.’’. 
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521 
(1) IN GENERAL.— 
(A) IN GENERAL.—Section 1833(a) of the 
Social Security Act (42 U.S.C. 1395l(a)) is 
amended by adding after and below paragraph 
(9) the following: 
‘‘With respect to Medicare covered preventive services, in 
any case in which the payment rate otherwise provided 
under this part is computed as a percent of less than 100 
percent of an actual charge, fee schedule rate, or other rate, 
such percentage shall be increased to 100 percent.’’. 
(B) APPLICATION TO SIGMOIDOSCOPIES AND 
COLONOSCOPIES.—Section 1834(d) of such Act 
(42 U.S.C. 1395m(d)) is amended— 
(i) in paragraph (2)(C), by amending 
clause (ii) to read as follows: 
‘‘(ii) NO COINSURANCE.—In the case of 
a beneficiary who receives services described 
in clause (i), there shall be no coinsurance 
applied.’’; and 
(ii) in paragraph (3)(C), by amending 
clause (ii) to read as follows: 
‘‘(ii) NO COINSURANCE.—In the case of 
a beneficiary who receives services described 
in clause (i), there shall be no coinsurance 
applied.’’. 
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522 
(2) ELIMINATION
OF
COINSURANCE
IN
OUT-
PATIENT HOSPITAL SETTINGS.— 
(A) EXCLUSION
FROM
OPD
FEE
SCHED-
ULE.—Section 1833(t)(1)(B)(iv) of the Social 
Security Act (42 U.S.C. 1395l(t)(1)(B)(iv)) is 
amended by striking ‘‘screening mammography 
(as defined in section 1861(jj)) and diagnostic 
mammography’’ and inserting ‘‘diagnostic mam-
mograms and Medicare covered preventive serv-
ices (as defined in section 1861(iii)(1))’’. 
(B) CONFORMING
AMENDMENTS.—Section 
1833(a)(2) of the Social Security Act (42 U.S.C. 
1395l(a)(2)) is amended— 
(i) in subparagraph (F), by striking 
‘‘and’’ after the semicolon at the end; 
(ii) in subparagraph (G), by adding 
‘‘and’’ at the end; and 
(iii) by adding at the end the following 
new subparagraph: 
‘‘(H) with respect to additional preventive 
services (as defined in section 1861(ddd)) fur-
nished by an outpatient department of a hos-
pital, the amount determined under paragraph 
(1)(W);’’. 
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528 
spect to marriage and family therapist serv-
ices under section 1861(s)(2)(GG), the 
amounts paid shall be 80 percent of the less-
er of the actual charge for the services or 75 
percent of the amount determined for pay-
ment of a psychologist under clause (L)’’. 
(B) DEVELOPMENT OF CRITERIA WITH RE-
SPECT TO CONSULTATION WITH A HEALTH CARE 
PROFESSIONAL.—The Secretary of Health and 
Human Services shall, taking into consideration 
concerns for patient confidentiality, develop cri-
teria with respect to payment for marriage and 
family therapist services for which payment may 
be made directly to the marriage and family 
therapist under part B of title XVIII of the So-
cial Security Act (42 U.S.C. 1395j et seq.) under 
which such a therapist must agree to consult 
with a patient’s attending or primary care phy-
sician or nurse practitioner in accordance with 
such criteria. 
(5) EXCLUSION OF MARRIAGE AND FAMILY THER-
APIST SERVICES FROM SKILLED NURSING FACILITY 
PROSPECTIVE
PAYMENT
SYSTEM.—Section 
1888(e)(2)(A)(ii) of the Social Security Act (42 
U.S.C. 1395yy(e)(2)(A)(ii)), as amended by section 
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530 
(A) in subparagraph (FF), by striking 
‘‘and’’ at the end; 
(B) in subparagraph (GG), by inserting 
‘‘and’’ at the end; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(HH) mental health counselor services (as de-
fined in subsection (kkk)(1));’’. 
(2) DEFINITION.—Section 1861 of the Social Se-
curity Act (42 U.S.C. 1395x), as previously amended, 
is amended by adding at the end the following new 
subsection: 
‘‘Mental Health Counselor Services 
‘‘(kkk)(1) The term ‘mental health counselor services’ 
means services performed by a mental health counselor (as 
defined in paragraph (2)) for the diagnosis and treatment 
of mental illnesses which the mental health counselor is le-
gally authorized to perform under State law (or the State 
regulatory mechanism provided by the State law) of the 
State in which such services are performed, as would other-
wise be covered if furnished by a physician or as incident 
to a physician’s professional service, but only if no facility 
or other provider charges or is paid any amounts with re-
spect to the furnishing of such services. 
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712 
ernization Act of 2003 (Public Law 108-173) is amended 
by striking ‘‘section 1886(h)(7)’’ and all that follows and 
inserting ‘‘paragraphs (7) and (8) of subsection (h) of sec-
tion 1886 of the Social Security Act.’’. 
SEC. 1502. INCREASING TRAINING IN NONPROVIDER SET-
TINGS. 
(a) DIRECT GME.—Section 1886(h)(4)(E) of the So-
cial Security Act (42 U.S.C. 1395ww(h)) is amended— 
(1) by designating the first sentence as a clause 
(i) with the heading ‘‘IN GENERAL.—’’ and appro-
priate indentation; 
(2) by striking ‘‘shall be counted and that all the 
time’’ and inserting ‘‘shall be counted and that— 
‘‘(I) effective for cost reporting pe-
riods beginning before July 1, 2009, all 
the time’’; 
(3) in subclause (I), as inserted by paragraph 
(1), by striking the period at the end and inserting 
‘‘; and’’; and 
(A) by inserting after subclause (I), as so 
inserted, the following: 
‘‘(II) effective for cost reporting 
periods beginning on or after July 1, 
2009, all the time so spent by a resi-
dent shall be counted towards the deter-
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PART 3—IMPROVING STAFF TRAINING 
SEC. 1431. DEMENTIA AND ABUSE PREVENTION TRAINING. 
(a) SKILLED NURSING FACILITIES.—Section 
1819(f)(2)(A)(i)(I) of the Social Security Act (42 
U.S.C. 1395i–3(f)(2)(A)(i)(I)) is amended by in-
serting ‘‘(including, in the case of initial train-
ing and, if the Secretary determines appro-
priate, in the case of ongoing training, demen-
tia management training and resident abuse 
prevention training)’’ after ‘‘curriculum’’. 
(b) 
NURSING
FACILITIES.—Section 
1919(f)(2)(A)(i)(I) of the Social Security Act (42 
U.S.C. 1396r(f)(2)(A)(i)(I)) is amended by in-
serting ‘‘(including, in the case of initial train-
ing and, if the Secretary determines appro-
priate, in the case of ongoing training, demen-
tia management training and resident abuse 
prevention training)’’ after ‘‘curriculum’’. 
(c) EFFECTIVE
DATE.—The amendments 
made by this section shall take effect 1 year 
after the date of the enactment of this Act. 
SEC. 1432. STUDY AND REPORT ON TRAINING REQUIRED 
FOR CERTIFIED NURSE AIDES AND SUPER-
VISORY STAFF. 
(a) STUDY.— 
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(1) IN GENERAL.—The Secretary shall 
conduct a study on the content of train-
ing for certified nurse aides and super-
visory staff of skilled nursing facilities 
and nursing facilities. The study shall in-
clude an analysis of the following: 
(A) Whether the number of initial 
training hours for certified nurse 
aides 
required 
under 
sections 
1819(f)(2)(A)(i)(II) 
and 
1919(f)(2)(A)(i)(II) of the Social Secu-
rity 
Act 
(42 
U.S.C. 
1395i– 
3(f)(2)(A)(i)(II); 
1396r(f)(2)(A)(i)(II)) 
should be increased from 75 and, if 
so, what the required number of ini-
tial training hours should be, includ-
ing any recommendations for the con-
tent of such training (including train-
ing related to dementia). 
(B) Whether requirements for on-
going training under such sections 
1819(f)(2)(A)(i)(II) 
and 
1919(f)(2)(A)(i)(II) should be increased 
from 12 hours per year, including any 
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