I 
110TH CONGRESS 
2D SESSION 
H. R. 7114 
To amend title XVIII of the Social Security Act to provide certain high 
cost Medicare beneficiaries suffering from multiple chronic conditions 
with access to Independence at Home services in lower cost treatment 
settings, such as their residences, under a plan of care developed by 
an Independence at Home physician or Independence at Home nurse 
practitioner. 
IN THE HOUSE OF REPRESENTATIVES 
SEPTEMBER 26, 2008 
Mr. MARKEY introduced the following bill; which was referred to the Com-
mittee on Ways and Means, and in addition to the Committee on Energy 
and Commerce, for a period to be subsequently determined by the Speak-
er, in each case for consideration of such provisions as fall within the ju-
risdiction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to provide 
certain high cost Medicare beneficiaries suffering from 
multiple chronic conditions with access to Independence 
at Home services in lower cost treatment settings, such 
as their residences, under a plan of care developed by 
an Independence at Home physician or Independence 
at Home nurse practitioner. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Independence at Home 
Act of 2008’’. 
SEC. 2. FINDINGS. 
Congress makes the following findings: 
(1) According to the November 2007 Congres-
sional Budget Office Long Term Outlook for Health 
Care Spending, unless changes are made to the way 
health care is delivered, growing demand for re-
sources caused by rising health care costs and to a 
lesser extent the nation’s expanding elderly popu-
lation will confront Americans with increasingly dif-
ficult choices between health care and other prior-
ities. However, opportunities exist to constrain 
health care costs without adverse health care con-
sequences. 
(2) Medicare beneficiaries with multiple chronic 
conditions account for a disproportionate share of 
Medicare spending compared to their representation 
in the overall Medicare population, and evidence sug-
gests that such patients often receive poorly coordi-
nated care, including conflicting information from 
health providers and different diagnoses of the same 
symptoms. 
(3) People with chronic conditions account for 
76 percent of all hospital admissions, 88 percent of 
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all prescriptions filled, and 72 percent of physician 
visits. 
(4) More than 60 percent of physicians treating 
patients with chronic conditions believe that their 
training did not adequately prepare them to coordi-
nate in-home and community services; educate pa-
tients with chronic conditions; manage the psycho-
logical and social aspects of chronic care; provide ef-
fective nutritional guidance; and manage chronic 
pain. 
(5) Recent studies cited by the Congressional 
Budget Office found substantial differences among 
regions of the country in the cost to Medicare of 
treating beneficiaries with multiple chronic condi-
tions with lower cost regions experiencing better out-
comes and lower mortality rates. These studies have 
suggested that Medicare spending could be reduced 
by 30 percent if more conservative practice styles 
were adopted, however, the current Medicare fee-for- 
service program creates incentives to provide frag-
mented, high cost health care services. 
(6) Studies show that hospital utilization and 
emergency room visits for patients with multiple 
chronic conditions can be reduced and significant 
savings can be achieved through the use of inter-
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disciplinary teams of health care professionals caring 
for patients in their places of residence. 
(7) The Independence at Home program, de-
signed to fund better health care and improved 
health care technology through savings it achieves, 
uses a patient-centered health care delivery model to 
permit the growing number of Medicare beneficiaries 
with multiple chronic conditions to remain as inde-
pendent as possible for as long as possible and to re-
ceive care in a setting that is preferred by the bene-
ficiary involved and the family of such beneficiary. 
(8) The Independence at Home program begins 
Medicare reform by creating incentives for practi-
tioners and providers to develop methods and tech-
nologies for providing better and lower cost health 
care to the highest cost Medicare beneficiaries with 
the greatest incentives provided in the case of high-
est cost beneficiaries. 
(9) The Independence at Home program incor-
porates lessons learned from prior demonstration 
projects and phase I of the Voluntary Chronic Care 
Improvement program under section 1807 of the So-
cial Security Act, enacted in sections 721 and 722 
of the Medicare Prescription Drug, Improvement 
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and Modernization Act of 2003 (Public Law 108– 
173). 
(10) The Independence at Home Act provides 
for a chronic care coordination demonstration for 
the highest cost Medicare beneficiaries with multiple 
chronic conditions that holds providers accountable 
for quality outcomes, patient satisfaction, and man-
datory minimum savings on an annual basis. 
(11) The Independence at Home Act generates 
savings by providing better, more coordinated care 
to the highest cost Medicare beneficiaries with mul-
tiple chronic conditions, reducing duplicative and un-
necessary services, and avoiding unnecessary hos-
pitalizations and emergency room visits. 
SEC. 3. ESTABLISHMENT OF VOLUNTARY INDEPENDENCE 
AT HOME CHRONIC CARE COORDINATION 
DEMONSTRATION PROJECT UNDER TRADI-
TIONAL MEDICARE FEE-FOR-SERVICE PRO-
GRAM. 
(a) IN GENERAL.—Title XVIII of the Social Security 
Act is amended— 
(1) by amending subsection (c) of section 1807 
(42 U.S.C. 1395b–8) to read as follows: 
‘‘(c) INDEPENDENCE AT HOME CHRONIC CARE CO-
ORDINATION DEMONSTRATION PROJECT.—A demonstra-
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tion project for Independence at Home chronic care co-
ordination programs for high cost Medicare beneficiaries 
with multiple chronic conditions is set forth in section 
1807A.’’; and 
(2) by inserting after section 1807 the following 
new section: 
‘‘INDEPENDENCE AT HOME CHRONIC CARE 
COORDINATION DEMONSTRATION PROJECT 
‘‘SEC. 1807A. (a) IN GENERAL.— 
‘‘(1) IMPLEMENTATION.—The Secretary shall, 
where possible, enter into agreements with at least 
two unaffiliated Independence at Home organiza-
tions, as described in this section, to provide chronic 
care coordination services for a period of three years 
in each of the 13 highest cost States and the Dis-
trict of Columbia and in 13 additional States that 
are representative of other regions of the United 
States. Such organizations shall have documented 
experience in furnishing the types of services covered 
by this section to eligible beneficiaries in non-institu-
tional settings using qualified teams of health care 
professionals that are directed by Independence at 
Home physicians or Independence at Home nurse 
practitioners and that use health information tech-
nology and individualized plans of care. 
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‘‘(2) ELIGIBILITY.—Any organization shall be 
eligible for an Independence at Home agreement in 
the developmental phase if it is an Independence at 
Home organization (as defined in subsection (b)(7)) 
and has the demonstrated capacity to provide the 
services covered under this section to the number of 
eligible 
beneficiaries 
specified 
in 
subsection 
(e)(3)(C). No organization shall be prohibited from 
participating because of its small size as long as it 
meets the eligibility requirements of this section. 
‘‘(3) INDEPENDENT
EVALUATION.—The Sec-
retary shall contract for an independent evaluation 
of the Independence at Home demonstration project 
under this section with an interim report to be pro-
vided after the first year and a final report to be 
provided after the third year of the project. Such an 
evaluation shall be conducted by a contractor with 
knowledge of chronic care coordination programs for 
the targeted patient population and demonstrated 
experience in the evaluation of such programs. Each 
such report shall include an assessment of the fol-
lowing factors and shall identify the characteristics 
of individual Independence at Home programs that 
are the most effective: 
‘‘(A) Quality improvement measures. 
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‘‘(B) Beneficiary, caregiver, and provider 
satisfaction. 
‘‘(C) Health outcomes appropriate for pa-
tients with multiple chronic conditions. 
‘‘(D) Cost savings to the program under 
this title. 
‘‘(4) AGREEMENTS.—The Secretary shall enter 
into agreements, beginning not later than one year 
after the date of the enactment of this section, with 
Independence at Home organizations that meet the 
participation requirements of this section, including 
minimum performance standards developed under 
subsection (e)(3), in order to provide access by eligi-
ble beneficiaries to Independence at Home programs 
under this section. 
‘‘(5) REGULATIONS.—At least three months be-
fore entering into the first agreement under this sec-
tion, the Secretary shall publish in the Federal Reg-
ister the specifications for implementing this section. 
‘‘(6) PERIODIC PROGRESS REPORTS.—Semi-an-
nually during the first year in which this section is 
implemented and annually thereafter during the pe-
riod of implementation of this section, the Secretary 
shall submit to the Committees on Ways and Means 
and Energy and Commerce of the House of Rep-
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resentatives and the Committee on Finance of the 
Senate a report that describes the progress of imple-
mentation of this section and explaining any vari-
ation from the Independence at Home program as 
described in this section. 
‘‘(b) DEFINITIONS.—For purposes of this section: 
‘‘(1) ACTIVITIES OF DAILY LIVING.—The term 
‘activities of daily living’ means bathing, dressing, 
grooming, transferring, feeding, or toileting. 
‘‘(2) CAREGIVER.—The term ‘caregiver’ means, 
with respect to an individual with a qualifying func-
tional impairment, a family member, friend, or 
neighbor who provides assistance to the individual. 
‘‘(3) ELIGIBLE BENEFICIARY.— 
‘‘(A) IN
GENERAL.—The term ‘eligible 
beneficiary’ means, with respect to an Inde-
pendence at Home program, an individual 
who— 
‘‘(i) is entitled to benefits under part 
A and enrolled under part B, but not en-
rolled in a plan under part C; 
‘‘(ii) has a qualifying functional im-
pairment and has been diagnosed with two 
or more of the chronic conditions described 
in subparagraph (C); and 
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‘‘(iii) within the 12 months prior to 
the individual first enrolling with an Inde-
pendence at Home program under this sec-
tion, has received benefits under this title 
for services described in each of clauses (i), 
(ii) and (iii) of subparagraph (D). 
‘‘(B) 
DISQUALIFICATIONS.—Such 
term 
does not include an individual— 
‘‘(i) who is receiving benefits under 
section 1881; 
‘‘(ii) who is enrolled in a PACE pro-
gram under section 1894; 
‘‘(iii) who is enrolled in (and is not 
disenrolled from) a chronic care improve-
ment program under section 1807; 
‘‘(iv) who within the previous year has 
been a resident for more than 90 days in 
a skilled nursing facility, a nursing facility 
(as defined in section 1919), or any other 
facility identified by the Secretary; 
‘‘(v) who resides in a setting that pre-
sents a danger to the safety of in-home 
health care providers and primary care-
givers; or 
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‘‘(vi) whose enrollment in an Inde-
pendence at Home program the Secretary 
determines would be inappropriate. 
‘‘(C) CHRONIC CONDITIONS DESCRIBED.— 
The chronic conditions described in this sub-
paragraph are the following: 
‘‘(i) Congestive heart failure. 
‘‘(ii) Diabetes. 
‘‘(iii) Chronic obstructive pulmonary 
disease. 
‘‘(iv) Ischemic heart disease. 
‘‘(v) Peripheral arterial disease. 
‘‘(vi) Stroke. 
‘‘(vii) Alzheimer’s Disease and other 
dementias designated by the Secretary. 
‘‘(viii) Pressure ulcers. 
‘‘(ix) Hypertension. 
‘‘(x) Neurodegenerative diseases des-
ignated by the Secretary which result in 
high costs under this title, including 
amyotropic lateral sclerosis (ALS), mul-
tiple sclerosis, and Parkinson’s disease. 
‘‘(xi) Any other chronic condition that 
the Secretary identifies as likely to result 
in high costs to the program under this 
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title when such condition is present in 
combination with one or more of the 
chronic conditions specified in the pre-
ceding clauses. 
‘‘(D) SERVICES DESCRIBED.—The services 
described in this subparagraph are the fol-
lowing: 
‘‘(i) Non-elective inpatient hospital 
services. 
‘‘(ii) Services in the emergency de-
partment of a hospital. 
‘‘(iii) Any of the following services: 
‘‘(I) Extended care services. 
‘‘(II) Services in an acute reha-
bilitation facility. 
‘‘(III) Home health services. 
‘‘(4) INDEPENDENCE AT HOME ASSESSMENT.— 
The term ‘Independence at Home assessment’ 
means, with respect to an eligible beneficiary, a com-
prehensive medical history, physical examination, 
and assessment of the beneficiary’s clinical and func-
tional status that— 
‘‘(A) is conducted by— 
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‘‘(i) an Independence at Home physi-
cian or an Independence at Home nurse 
practitioner; 
‘‘(ii) a physician assistant, nurse prac-
titioner, or clinical nurse specialist, as de-
fined in section 1861(aa)(5), who is em-
ployed by an Independence at Home orga-
nization and is working in collaboration 
with an Independence at Home physician 
or Independence at Home nurse practi-
tioner; or 
‘‘(iii) any other health care profes-
sional that meets such conditions as the 
Secretary may specify; and 
‘‘(B) includes an assessment of— 
‘‘(i) activities of daily living and other 
co-morbidities; 
‘‘(ii) medications and medication ad-
herence; 
‘‘(iii) affect, cognition, executive func-
tion, and presence of mental disorders; 
‘‘(iv) functional status, including mo-
bility, balance, gait, risk of falling, and 
sensory function; 
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‘‘(v) social functioning and social inte-
gration; 
‘‘(vi) environmental needs and a safe-
ty assessment; 
‘‘(vii) the ability of the beneficiary’s 
primary caregiver to assist with the bene-
ficiary’s care as well as the caregiver’s own 
physical and emotional capacity, education, 
and training; 
‘‘(viii) whether the beneficiary is likely 
to benefit from an Independence at Home 
program; 
‘‘(ix) whether the conditions in the 
beneficiary’s home or place of residence 
would permit the safe provision of services 
in the home or residence, respectively, 
under an Independence at Home program; 
and 
‘‘(x) other factors determined appro-
priate by the Secretary. 
‘‘(5) INDEPENDENCE AT HOME CARE TEAM.— 
The term ‘Independence at Home care team’— 
‘‘(A) means, with respect to a participant, 
a team of qualified individuals that provides 
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services to the participant as part of an Inde-
pendence at Home program; and 
‘‘(B) includes an Independence at Home 
physician or an Independence at Home nurse 
practitioner and an Independence at Home co-
ordinator (who may also be an Independence at 
Home physician or an Independence at Home 
nurse practitioner). 
‘‘(6) 
INDEPENDENCE
AT
HOME
COORDI-
NATOR.—The term ‘Independence at Home coordi-
nator’ means, with respect to a participant, an indi-
vidual who— 
‘‘(A) is employed by an Independence at 
Home organization and is responsible for co-
ordinating all of the elements of the partici-
pant’s Independence at Home plan; 
‘‘(B) is a licensed health professional, such 
as a physician, registered nurse, nurse practi-
tioner, clinical nurse specialist, physician assist-
ant, or other health care professional as the 
Secretary determines appropriate, who has at 
least one year of experience providing and co-
ordinating medical and related services for indi-
viduals in their homes; and 
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‘‘(C) serves as the primary point of contact 
responsible for communications with the partici-
pant and for facilitating communications with 
other health care providers under the plan. 
‘‘(7) INDEPENDENCE
AT
HOME
ORGANIZA-
TION.—The term ‘Independence at Home organiza-
tion’ means a provider of services, a physician or 
physician group practice, a nurse practitioner or 
nurse practitioner group practice, or other legal enti-
ty which receives payment for services furnished 
under this title (other than only under this section) 
and which— 
‘‘(A) has entered into an agreement under 
subsection (a)(2) to provide an Independence at 
Home program under this section; 
‘‘(B)(i) is able to provide all of the ele-
ments of the Independence at Home plan in a 
participant’s home or place of residence, or 
‘‘(ii) if the organization is not able to pro-
vide all such elements in such home or resi-
dence, has adequate mechanisms for ensuring 
the provision of such elements by one or more 
qualified entities; 
‘‘(C) has Independence at Home physi-
cians, clinical nurse specialists, nurse practi-
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tioners, or physician assistants available to re-
spond to patient emergencies 24 hours a day, 
seven days a week; 
‘‘(D) accepts all eligible beneficiaries from 
the organization’s service area except to the ex-
tent that qualified staff are not available; and 
‘‘(E) meets other requirements for such an 
organization under this section. 
‘‘(8) INDEPENDENCE
AT
HOME
PHYSICIAN.— 
The term ‘Independence at Home physician’ means 
a physician who— 
‘‘(A) is employed by or affiliated with an 
Independence at Home organization, as re-
quired under paragraph (7)(C), or has another 
contractual relationship with the Independence 
at Home organization that requires the physi-
cian to be responsible for the plans of care for 
the physician’s patients; 
‘‘(B) is certified— 
‘‘(i) by the American Board of Family 
Physicians, the American Board of Inter-
nal Medicine, the American Osteopathic 
Board of Family Physicians, the American 
Osteopathic Board of Internal Medicine, 
the American Board of Emergency Medi-
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cine, or the American Board of Physical 
Medicine and Rehabilitation; or 
‘‘(ii) by a Board recognized by the 
American Board of Medical Specialties and 
determined by the Secretary to be appro-
priate for the Independence at Home pro-
gram; 
‘‘(C) has— 
‘‘(i) a certification in geriatric medi-
cine as provided by American Board of 
Medical Specialties; or 
‘‘(ii) passed the clinical competency 
examination of the American Academy of 
Home Care Physicians and has substantial 
experience in the delivery of medical care 
in the home, including at least two years 
of experience in the management of Medi-
care patients and one year of experience in 
home-based medical care including at least 
200 house calls; and 
‘‘(D) has furnished services during the pre-
vious 12 months for which payment is made 
under this title. 
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‘‘(9) INDEPENDENCE AT HOME NURSE PRACTI-
TIONER.—The term ‘Independence at Home nurse 
practitioner’ means a nurse practitioner who— 
‘‘(A) is employed by or affiliated with an 
Independence at Home organization, as re-
quired under paragraph (7)(C), or has another 
contractual relationship with the Independence 
at Home organization that requires the nurse 
practitioner to be responsible for the plans of 
care for the nurse practitioner’s patients; 
‘‘(B) practices in accordance with State 
law regarding scope of practice for nurse practi-
tioners; 
‘‘(C) is certified— 
‘‘(i) as a Gerontologic Nurse Practi-
tioner by the American Academy of Nurse 
Practitioners Certification Program or the 
American Nurses Credentialing Center; or 
‘‘(ii) as a family nurse practitioner or 
adult nurse practitioner by the American 
Academy of Nurse Practitioners Certifi-
cation Board or the American Nurses 
Credentialing Center and holds a certifi-
cate of Added Qualification in gerontology, 
elder care or care of the older adult pro-
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vided by the American Academy of Nurse 
Practitioners, 
the 
American 
Nurses 
Credentialing Center or a national nurse 
practitioner certification board deemed by 
the Secretary to be appropriate for an 
Independence at Home program; and 
‘‘(D) has furnished services during the pre-
vious 12 months for which payment is made 
under this title. 
‘‘(10) INDEPENDENCE
AT
HOME
PLAN.—The 
term ‘Independence at Home plan’ means a plan es-
tablished under subsection (d)(2) for a specific par-
ticipant in an Independence at Home program. 
‘‘(11) INDEPENDENCE AT HOME PROGRAM.— 
The term ‘Independence at Home program’ means a 
program described in subsection (d) that is operated 
by an Independence at Home organization. 
‘‘(12) PARTICIPANT.—The term ‘participant’ 
means an eligible beneficiary who has voluntarily en-
rolled in an Independence at Home program. 
‘‘(13) QUALIFIED ENTITY.—The term ‘qualified 
entity’ means a person or organization that is li-
censed or otherwise legally permitted to provide the 
specific element (or elements) of an Independence at 
Home plan that the entity has agreed to provide. 
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‘‘(14) 
QUALIFYING
FUNCTIONAL
IMPAIR-
MENT.—The term ‘qualifying functional impairment’ 
means an inability to perform, without the assist-
ance of another person, two or more activities of 
daily living. 
‘‘(c) IDENTIFICATION AND ENROLLMENT OF PRO-
SPECTIVE PROGRAM PARTICIPANTS.— 
‘‘(1) NOTICE TO ELIGIBLE INDEPENDENCE AT 
HOME BENEFICIARIES.—The Secretary shall develop 
a model notice to be made available to Medicare 
beneficiaries (and to their caregivers) who are poten-
tially eligible for an Independence at Home program 
by participating providers and by Independence at 
Home programs. Such notice shall include the fol-
lowing information: 
‘‘(A) A description of the potential advan-
tages to the beneficiary participating in an 
Independence at Home program. 
‘‘(B) A description of the eligibility re-
quirements to participate. 
‘‘(C) Notice that participation is voluntary. 
‘‘(D) A statement that all other Medicare 
benefits remain available to beneficiaries who 
enroll in an Independence at Home program. 
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‘‘(E) Notice that those who enroll in an 
Independence at Home program may have co- 
payments for house calls by Independence at 
Home physicians or by Independence at Home 
nurse practitioners reduced or eliminated at the 
discretion of the Independence at Home physi-
cian or Independence at Home nurse practi-
tioner involved. 
‘‘(F) A description of the services that 
could potentially be provided under an Inde-
pendence at Home plan. 
‘‘(G) A description of the method for par-
ticipating, or withdrawing from participation, in 
an Independence at Home program or becoming 
no longer eligible to so participate. 
‘‘(2) 
VOLUNTARY
PARTICIPATION
AND 
CHOICE.—An eligible beneficiary may participate in 
an Independence at Home program through enroll-
ment in such program on a voluntary basis and may 
terminate such participation at any time. Such a 
beneficiary may also receive Independence at Home 
services from the Independence at Home organiza-
tion of the beneficiary’s choice but may not receive 
Independence at Home services from more than one 
Independence at Home organization at a time. 
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‘‘(d) INDEPENDENCE AT HOME PROGRAM REQUIRE-
MENTS.— 
‘‘(1) IN
GENERAL.—Each Independence at 
Home program shall, for each participant enrolled in 
the program— 
‘‘(A) designate— 
‘‘(i) an Independence at Home physi-
cian or an Independence at Home nurse 
practitioner; and 
‘‘(ii) an Independence at Home coor-
dinator; 
‘‘(B) have a process to ensure that the 
participant received an Independence at Home 
assessment before enrollment in the program; 
‘‘(C) with the participation of the partici-
pant (or the participant’s representative or 
caregiver), an Independence at Home physician 
or an Independence at Home nurse practitioner, 
and Independence at Home coordinator, develop 
an Independence at Home plan for the partici-
pant in accordance with paragraph (2); 
‘‘(D) ensure that the participant receives 
an Independence at Home assessment at least 
annually after the original assessment to ensure 
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that the Independence at Home plan for the 
participant remains current and appropriate; 
‘‘(E) implement all of the elements of the 
participant’s Independence at Home plan and 
in instances in which the Independence at 
Home organization does not provide specific ele-
ments of the Independence at Home plan, en-
sure that qualified entities successfully imple-
ment those specific elements; 
‘‘(F) provide for an electronic medical 
record and electronic health information tech-
nology to coordinate the participant’s care and 
to exchange information with the Medicare pro-
gram and electronic monitoring and commu-
nication technologies and mobile diagnostic and 
therapeutic technologies as appropriate and ac-
cepted by the participant; and 
‘‘(G) respect the participant’s right to 
health information privacy and obtain permis-
sion from the participant (or responsible per-
son) for the use and disclosure of identifiable 
health information necessary for treatment, 
payment, or health care operations. 
‘‘(2) INDEPENDENCE AT HOME PLAN.— 
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‘‘(A) IN GENERAL.—An Independence at 
Home plan for a participant shall be developed 
with the participant, an Independence at Home 
physician or an Independence at Home nurse 
practitioner, an Independence at Home coordi-
nator, and, if appropriate, one or more of the 
participant’s caregivers and shall— 
‘‘(i) document the chronic conditions, 
co-morbidities, and other health needs 
identified in the participant’s Independence 
at Home assessment; 
‘‘(ii) determine which elements of an 
Independence at Home plan described in 
subparagraph (C) are appropriate for the 
participant; and 
‘‘(iii) identify the qualified entity re-
sponsible for providing each element of 
such plan. 
‘‘(B) COMMUNICATION OF INDIVIDUALIZED 
INDEPENDENCE AT HOME PLAN TO THE INDE-
PENDENCE
AT
HOME
COORDINATOR.—If the 
Independence at Home physician or Independ-
ence at Home nurse practitioner responsible for 
conducting the participant’s Independence at 
Home assessment and developing the Independ-
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ence at Home plan is not the participant’s 
Independence at Home coordinator, the Inde-
pendence at Home physician or Independence 
at Home nurse practitioner is responsible for 
ensuring that the participant’s Independence at 
Home coordinator has such plan and is familiar 
with the requirements of the plan and has the 
appropriate contact information for all of the 
members of the Independence at Home care 
team. 
‘‘(C) ELEMENTS
OF
INDEPENDENCE
AT 
HOME PLAN.—An Independence at Home orga-
nization shall have the capability to provide, di-
rectly or through a qualified entity, and shall 
offer all of the following elements of an Inde-
pendence at Home plan to the extent they are 
appropriate and accepted by a participant: 
‘‘(i) Self-care education and preven-
tive care consistent with the participant’s 
condition. 
‘‘(ii) Coordination of all medical treat-
ment furnished to the participant, regard-
less of whether such treatment is covered 
and available to the participant under this 
title. 
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‘‘(iii) Information about, and access 
to, hospice care. 
‘‘(iv) Pain and palliative care and end- 
of-life care. 
‘‘(v) Education for primary caregivers 
and family members. 
‘‘(vi) Caregiver counseling services 
and information about, and referral to, 
other caregiver support and health care 
services in the community. 
‘‘(vii) Monitoring and management of 
medications as well as assistance to par-
ticipants and their caregivers with respect 
to selection of a prescription drug plan 
under part D that best meets the needs of 
the participant’s chronic conditions. 
‘‘(viii) Referral to social services, such 
as personal care, meals, volunteers, and in-
dividual and family therapy. 
‘‘(ix) Access to phlebotomy and ancil-
lary laboratory and imaging services, in-
cluding point of care laboratory and imag-
ing diagnostics. 
‘‘(3) PRIMARY TREATMENT ROLE WITHIN AN 
INDEPENDENCE AT HOME CARE TEAM .—An Inde-
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pendence at Home physician or an Independence at 
Home nurse practitioner may assume the primary 
treatment role as permitted under State law. 
‘‘(4) ADDITIONAL RESPONSIBILITIES.— 
‘‘(A) OUTCOMES
REPORT.—Each Inde-
pendence at Home organization offering an 
Independence at Home program shall monitor 
and report to the Secretary, in a manner speci-
fied by the Secretary, on— 
‘‘(i) patient outcomes; 
‘‘(ii) beneficiary, caregiver, and pro-
vider satisfaction with respect to coordina-
tion of the participant’s care; and 
‘‘(iii) the achievement of mandatory 
minimum savings described in subsection 
(e)(6). 
‘‘(B) ADDITIONAL REQUIREMENTS.—Each 
such organization and program shall comply 
with such additional requirements as the Sec-
retary may specify. 
‘‘(e) TERMS AND CONDITIONS.— 
‘‘(1) IN GENERAL.—An agreement under this 
section with an Independence at Home organization 
shall contain such terms and conditions as the Sec-
retary may specify consistent with this section. 
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‘‘(2) CLINICAL, QUALITY
IMPROVEMENT, AND 
FINANCIAL
REQUIREMENTS.—The Secretary may 
not enter into an agreement with such an organiza-
tion under this section for the operation of an Inde-
pendence at Home program unless— 
‘‘(A) the program and organization meet 
the requirements of subsection (d), minimum 
quality and performance standards developed 
under paragraph (3), and such clinical, quality 
improvement, financial, and other requirements 
as the Secretary deems to be appropriate for 
participants to be served; and 
‘‘(B) the organization demonstrates to the 
satisfaction of the Secretary that the organiza-
tion is able to assume financial risk for per-
formance under the agreement with respect to 
payments made to the organization under such 
agreement through available reserves, reinsur-
ance, or withholding of funding provided under 
this title, or such other means as the Secretary 
determines appropriate. 
‘‘(3) MINIMUM
QUALITY
AND
PERFORMANCE 
STANDARDS.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
develop mandatory minimum quality and per-
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formance standards for Independence at Home 
organizations and programs. 
‘‘(B) STANDARDS
TO
BE
INCLUDED.— 
Such standards shall include measures of— 
‘‘(i) participant outcomes; 
‘‘(ii) satisfaction of the beneficiary, 
caregiver, and provider involved; and 
‘‘(iii) cost savings consistent with 
paragraph (6). 
‘‘(C) MINIMUM
PARTICIPATION
STAND-
ARD.—Such standards shall include a require-
ment that, for any year after the first year, an 
Independence at Home program had an average 
number of participants during the previous year 
of at least 100 participants. 
‘‘(4) TERM
OF
AGREEMENT
AND
MODIFICA-
TION.—The agreement under this subsection shall 
be, subject to paragraphs (3)(C) and (5), for a pe-
riod of three years, and the terms and conditions 
may be modified during the contract period only 
upon the request of the Independence at Home orga-
nization. 
‘‘(5) TERMINATION
AND
NON-RENEWAL
OF 
AGREEMENT.— 
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‘‘(A) IN GENERAL.—If the Secretary deter-
mines that an Independence at Home organiza-
tion has failed to meet the minimum perform-
ance standards under paragraph (3) or other 
requirements under this section, the Secretary 
may terminate the agreement of the organiza-
tion at the end of the contract year. 
‘‘(B) REQUIRED
TERMINATION
WHERE 
RISK TO HEALTH OR SAFETY OF A PARTICI-
PANT.—The Secretary shall terminate an agree-
ment with an Independence at Home organiza-
tion at any time the Secretary determines that 
the care being provided by such organization 
poses a threat to the health and safety of a par-
ticipant. 
‘‘(C) TERMINATION BY INDEPENDENCE AT 
HOME
ORGANIZATIONS.—Notwithstanding any 
other provision of this subsection, an Independ-
ence at Home organization may terminate an 
agreement with the Secretary under this section 
to provide an Independence at Home program 
at the end of a contract year if the organization 
provides to the Secretary and to the bene-
ficiaries participating in the program notifica-
tion of such termination more than 90 days be-
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fore the end of such year. Paragraphs (6), (8), 
and (9)(B) shall apply to the organization until 
the date of termination. 
‘‘(D) NOTICE
OF
INVOLUNTARY
TERMI-
NATION.—The Secretary shall notify the par-
ticipants in an Independence at Home program 
as soon as practicable if a determination is 
make to terminate an agreement with the Inde-
pendence at Home organization involuntarily as 
provided in subparagraphs (A) and (B). Such 
notice shall inform the beneficiary of any other 
Independence at Home organizations that 
might be available to the beneficiary. 
‘‘(6) MANDATORY MINIMUM SAVINGS.— 
‘‘(A) IN GENERAL.—Under an agreement 
under this subsection, each Independence at 
Home organization shall ensure that during any 
year of the agreement for its Independence at 
Home program, there is an aggregate savings 
in the cost to the program under this title for 
participating beneficiaries, as calculated under 
subparagraph (B), that is not less than the 
product of— 
‘‘(i) 5 percent of the estimated aver-
age monthly costs that would have been in-
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curred under parts A, B, and D if those 
beneficiaries had not participated in the 
Independence at Home program; and 
‘‘(ii) the number of participant- 
months for that year. 
‘‘(B) COMPUTATION OF AGGREGATE SAV-
INGS.— 
‘‘(i) MODEL FOR CALCULATING SAV-
INGS.—The Secretary shall contract with a 
nongovernmental organization or academic 
institution to independently develop an an-
alytical model for determining whether an 
Independence at Home program achieves 
at least savings required under subpara-
graph (A) relative to costs that would have 
been incurred by Medicare in the absence 
of Independence at Home programs. The 
analytical model developed by the inde-
pendent research organization for making 
these determinations shall utilize state-of- 
the-art econometric techniques, such as 
Heckman’s selection correction methodolo-
gies, to account for sample selection bias, 
omitted variable bias, or problems with 
endogeneity. 
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‘‘(ii) APPLICATION OF THE MODEL.— 
Using the model developed under clause 
(i), the Secretary shall compare the actual 
costs to Medicare of beneficiaries partici-
pating in an Independence at Home pro-
gram to the predicted costs to Medicare of 
such beneficiaries to determine whether an 
Independence at Home program achieves 
the savings required under subparagraph 
(A). 
‘‘(iii) REVISIONS
OF
THE
MODEL.— 
The Secretary shall require that the model 
developed under clause (i) for determining 
savings shall be designed according to in-
structions that will control, or adjust for, 
inflation as well as risk factors including, 
age, race, gender, disability status, socio-
economic status, region of country (such as 
State, county, metropolitan statistical area, 
or zip code), and such other factors as the 
Secretary determines to be appropriate, in-
cluding adjustment for prior health care 
utilization. The Secretary may add to, 
modify, or substitute for such adjustment 
factors if such changes will improve the 
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sensitivity or specificity of the calculation 
of costs savings. 
‘‘(iv) PARTICIPANT-MONTH.—In mak-
ing the calculation described in subpara-
graph (A), each month or part of a month 
in a program year that a beneficiary par-
ticipates in an Independence at Home pro-
gram shall be counted as a ‘participant- 
month’. 
‘‘(C) NOTICE OF SAVINGS CALCULATION.— 
No later than 120 days before the beginning of 
any Independence at Home program year, the 
Secretary shall publish in the Federal Register 
a description of the model developed under sub-
paragraph (B)(i) and information for calcu-
lating savings required under subparagraph 
(A), including any revisions, sufficient to permit 
Independence at Home organizations to deter-
mine the savings they will be required to 
achieve during the program year to meet the 
savings requirement under such subparagraph. 
In order to facilitate this notice, the Secretary 
may designate a single annual date for the be-
ginning of all Independence at Home program 
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years that shall not be later than one year from 
the date of enactment of this section. 
‘‘(7) MANNER OF PAYMENT.—Subject to para-
graph (8), payments shall be made by the Secretary 
to an Independence at Home organization at a rate 
negotiated between the Secretary and the organiza-
tion under the agreement for— 
‘‘(A) Independence at Home assessments; 
and 
‘‘(B) on a per-participant, per-month basis 
for the items and services required to be pro-
vided or made available under subsection (d). 
‘‘(8) ENSURING
MANDATORY
MINIMUM
SAV-
INGS.—The Secretary shall require any Independ-
ence at Home organization that fails in any year to 
achieve the mandatory minimum savings described 
in paragraph (6) to provide those savings by refund-
ing payments made to the organization under para-
graph (7) during such year. 
‘‘(9) BUDGET
NEUTRAL
PAYMENT
CONDI-
TION.— 
‘‘(A) IN
GENERAL.—Under this section, 
the Secretary shall ensure that the cumulative, 
aggregate sum of Medicare program benefit ex-
penditures under parts A, B, and D for partici-
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pants in Independence at Home programs and 
funds paid to Independence at Home organiza-
tions under this section, shall not exceed the 
Medicare program benefit expenditures under 
such parts that the Secretary estimates would 
have been made for such participants in the ab-
sence of such programs. 
‘‘(B) TREATMENT
OF
SAVINGS.—If an 
Independence at Home organization achieves 
aggregate savings in a year in excess of the 
mandatory minimum savings described in para-
graph (6), 80 percent of such aggregate savings 
shall be paid to the organization and the re-
mainder shall be retained by the programs 
under this title. 
‘‘(f) 
WAIVER
OF
COINSURANCE
FOR
HOUSE 
CALLS.—A physician or nurse practitioner furnishing 
services in the home or residence of a participant in an 
Independence at Home program may waive collection of 
any coinsurance that might otherwise be payable under 
section 1833(a) with respect to such services. 
‘‘(g) REPORT.—Not later than one year after the end 
of the Independence at Home demonstration project under 
this section, the Secretary shall submit to Congress a re-
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port on such project. Such report shall include information 
on— 
‘‘(1) whether Independence at Home programs 
under the project met the performance standards for 
beneficiary, caregiver, and provider satisfaction; and 
‘‘(2) participant outcomes and cost savings, as 
well as the characteristics of the programs that were 
most effective and whether the participant eligibility 
criteria identified beneficiaries who were in the top 
ten percent of the highest cost Medicare bene-
ficiaries.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) Section 1833(a) of such Act (42 U.S.C. 
1395l(a)) is amended, in the matter before para-
graph (1), by inserting ‘‘and section 1807A(f)’’ after 
‘‘section 1876’’. 
(2) Section 1128B(b)(3) of such Act (42 U.S.C. 
1320a–7b(b)(3)) is amended— 
(A) by striking ‘‘and’’ at the end of sub-
paragraph (G); 
(B) by striking ‘‘1853(a)(4).’’ at the end of 
the first subparagraph (H) and inserting 
‘‘1853(a)(4);’’; 
(C) by redesignating the second subpara-
graph (H) as subparagraph (I) and by striking 
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the period at the end and inserting ‘‘; and’’; 
and 
(D) by adding at the end the following new 
subparagraph: 
‘‘(J) a waiver of coinsurance under section 
1807A(f).’’. 
Æ 
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