pendence at Home chronic care coordination programs for 
high cost Medicare beneficiaries with multiple chronic con-
ditions is set forth in section 1807A.’’; and 
(2) by inserting after section 1807 the following 
new section: 
‘‘INDEPENDENCE AT HOME CHRONIC CARE 
COORDINATION PILOT PROJECT 
‘‘SEC. 1807A. (a) IMPLEMENTATION.— 
‘‘(1) IN GENERAL.—The Secretary shall provide 
for the phased in development, implementation, and 
evaluation of Independence at Home programs de-
scribed in this section to meet the following objec-
tives: 
‘‘(A) To improve patient outcomes, com-
pared to comparable beneficiaries who do not 
participate in such a program, through reduced 
hospitalizations, nursing home admissions, or 
emergency room visits, increased symptom self- 
management, and similar results. 
‘‘(B) To improve satisfaction of patients 
and caregivers, as demonstrated through a 
quantitative pre-test and post-test survey devel-
oped by the Secretary that measures patient 
and caregiver satisfaction of care coordination, 
educational information, timeliness of response, 
and similar care features. 
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‘‘(C) To achieve a minimum of 5 percent 
cost savings in the care of beneficiaries under 
this title suffering from multiple high cost 
chronic diseases. 
‘‘(2) INITIAL IMPLEMENTATION (PHASE I).— 
‘‘(A) IN GENERAL.—In carrying out this 
section and to the extent possible, the Secretary 
shall enter into agreements with at least two 
unaffiliated Independence at Home organiza-
tions in each of the 13 highest cost States 
(based on average per capita expenditures per 
State under this title), in the District of Colum-
bia, and in 13 additional States that are rep-
resentative of other regions of the United 
States and include medically underserved rural 
and urban areas, to provide chronic care coordi-
nation services for a period of three years or 
until those agreements are terminated by the 
Secretary. Such agreements under this para-
graph shall continue in effect until the Sec-
retary makes the determination described in 
paragraph (3) or until those agreements are 
supplanted by new agreements under such 
paragraph. The phase of implementation under 
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this paragraph is referred to in this section as 
the ‘initial implementation’ phase or ‘phase I’. 
‘‘(B) PREFERENCE.—In selecting Inde-
pendence at Home organizations under this 
paragraph, the Secretary shall give a pref-
erence, to the extent practicable, to organiza-
tions that— 
‘‘(i) have documented experience in 
furnishing the types of services covered by 
this section to eligible beneficiaries in the 
home or place of residence using qualified 
teams of health care professionals that are 
directed by individuals who have the quali-
fications of Independence at Home physi-
cians, or in cases when such direction is 
provided by an Independence at Home 
physician to a physician assistant who has 
at least one year of experience providing 
gerontological medical and related services 
for chronically ill individuals in their 
homes, or other similar qualification as de-
termined by the Secretary to be appro-
priate for the Independence at Home pro-
gram, by the physician assistant acting 
under the supervision of an Independence 
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at Home physician and as permitted under 
State law, or Independence at Home nurse 
practitioners; 
‘‘(ii) have the capacity to provide serv-
ices covered by this section to at least 150 
eligible beneficiaries; and 
‘‘(iii) use electronic medical records, 
health information technology, and individ-
ualized plans of care. 
‘‘(3) 
EXPANDED
IMPLEMENTATION
PHASE 
(PHASE II).— 
‘‘(A) IN GENERAL.—For periods beginning 
after the end of the 3-year initial implementa-
tion period under paragraph (2), subject to sub-
paragraph (B), the Secretary shall renew agree-
ments described in paragraph (2) with Inde-
pendence at Home organization that have met 
all 3 objectives specified in paragraph (1) and 
enter into agreements described in paragraph 
(2) with any other organization that is located 
in any State or the District of Columbia, that 
was not an Independence at Home organization 
during the initial implementation period, and 
that meets the qualifications of an Independ-
ence at Home organization under this section. 
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The Secretary may terminate and not renew 
such an agreement with an organization that 
has not met such objectives during the initial 
implementation period. The phase of implemen-
tation under this paragraph is referred to in 
this section as the ‘expanded implementation’ 
phase or ‘phase II’. 
‘‘(B) CONTINGENCY.—The expanded im-
plementation under subparagraph (A) shall not 
occur if the Secretary finds, not later than 60 
days after the date of issuance of the inde-
pendent evaluation under paragraph (5), that 
continuation of the Independence at Home 
project is not in the best interest of bene-
ficiaries under this title or in the best interest 
of Federal health care programs. 
‘‘(4) ELIGIBILITY.—No organization shall be 
prohibited from participating under this section dur-
ing expanded implementation phase under para-
graph (3) (and, to the extent practicable, during ini-
tial implementation phase under paragraph (2)) be-
cause of its small size as long as it meets the eligi-
bility requirements of this section. 
‘‘(5) INDEPENDENT EVALUATIONS.— 
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‘‘(A) IN
GENERAL.—The Secretary shall 
contract for an independent evaluation of the 
initial implementation phase under paragraph 
(2) with an interim report to Congress to be 
provided on such evaluation as soon as prac-
ticable after the first year of such phase and a 
final report to be provided to Congress as soon 
as practicable following the conclusion of the 
initial implementation phase, but not later than 
6 months following the end of such phase. Such 
an evaluation shall be conducted by individuals 
with knowledge of chronic care coordination 
programs for the targeted patient population 
and demonstrated experience in the evaluation 
of such programs. 
‘‘(B) INFORMATION
TO
BE
INCLUDED.— 
Each such report shall include an assessment of 
the following factors and shall identify the char-
acteristics of individual Independence at Home 
programs that are the most effective in pro-
ducing improvements in— 
‘‘(i) beneficiary, caregiver, and pro-
vider satisfaction; 
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‘‘(ii) health outcomes appropriate for 
patients with multiple chronic diseases; 
and 
‘‘(iii) cost savings to the program 
under this title, such as in reducing— 
‘‘(I) hospital and skilled nursing 
facility admission rates and lengths of 
stay; 
‘‘(II) hospital readmission rates; 
and 
‘‘(III) emergency department vis-
its. 
‘‘(C) BREAKDOWN BY CONDITION.—Each 
such report shall include data on performance 
of Independence at Home organizations in re-
sponding to the needs of eligible beneficiaries 
with specific chronic conditions and combina-
tions of conditions, as well as the overall eligible 
beneficiary population. 
‘‘(6) AGREEMENTS.— 
‘‘(A) IN
GENERAL.—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 organiza-
tions that meet the participation requirements 
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of this section, including minimum performance 
standards developed under subsection (e)(3), in 
order to provide access by eligible beneficiaries 
to Independence at Home programs under this 
section. 
‘‘(B) AUTHORITY.—If the Secretary deems 
it necessary to serve the best interest of the 
beneficiaries under this title or the best interest 
of Federal health care programs, the Secretary 
may— 
‘‘(i) require screening of all potential 
Independence at Home organizations, in-
cluding 
owners, 
(such 
as 
through 
fingerprinting, licensure checks, site-visits, 
and other database checks) before entering 
into an agreement; 
‘‘(ii) require a provisional period dur-
ing which a new Independence at Home or-
ganization would be subject to enhanced 
oversight (such as prepayment review, un-
announced site visits, and payment caps); 
and 
‘‘(iii) require applicants to disclose 
previous affiliation with entities that have 
uncollected Medicare or Medicaid debt, and 
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authorize the denial of enrollment if the 
Secretary determines that these affiliations 
pose undue risk to the program. 
‘‘(7) 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. 
Such specifications shall describe the implementation 
process from initial to final implementation phases, 
including how the Secretary will identify and notify 
potential enrollees and how and when beneficiaries 
may enroll and disenroll from Independence at 
Home programs and change the programs in which 
they are enrolled. 
‘‘(8) 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-
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. 
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‘‘(9) ANNUAL BEST PRACTICES CONFERENCE.— 
During the initial implementation phase and to the 
extent practicable at intervals thereafter, the Sec-
retary shall provide for an annual Independence at 
Home teleconference for Independence at Home or-
ganizations to share best practices and review treat-
ment interventions and protocols that were success-
ful in meeting all 3 objectives specified in paragraph 
(1). 
‘‘(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; 
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‘‘(ii) has a qualifying functional im-
pairment and has been diagnosed with two 
or more of the chronic conditions described 
in subparagraph (C); and 
‘‘(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 part A for 
the following services: 
‘‘(I) Non-elective inpatient hos-
pital services. 
‘‘(II) Services in the emergency 
department of a hospital. 
‘‘(III) Any one of the following: 
‘‘(aa) Skilled nursing or sub- 
acute rehabilitation services in a 
Medicare-certified nursing facil-
ity. 
‘‘(bb) Comprehensive acute 
rehabilitation facility or Com-
prehensive outpatient rehabilita-
tion facility services. 
‘‘(cc) Skilled nursing or re-
habilitation services through a 
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Medicare-certified home health 
agency. 
‘‘(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 a 12-month period 
has been a resident for more than 90 days 
in a skilled nursing facility, a nursing facil-
ity (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 
‘‘(vi) whose enrollment in an Inde-
pendence at Home program the Secretary 
determines would be inappropriate. 
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‘‘(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 
title when such condition is present in 
combination with one or more of the 
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chronic conditions specified in the pre-
ceding clauses. 
‘‘(4) INDEPENDENCE AT HOME ASSESSMENT.— 
The term ‘Independence at Home assessment’ 
means a determination of eligibility of an individual 
for an Independence at Home program as an eligible 
beneficiary (as defined in paragraph (3)), a com-
prehensive medical history, physical examination, 
and assessment of the beneficiary’s clinical and func-
tional status that— 
‘‘(A) is conducted in person by an indi-
vidual— 
‘‘(i) who— 
‘‘(I) is an Independence at Home 
physician or an Independence at 
Home nurse practitioner; or 
‘‘(II) a physician assistant, nurse 
practitioner, or clinical nurse spe-
cialist, 
as 
defined 
in 
section 
1861(aa)(5), who is employed by an 
Independence at Home organization 
and is supervised by an Independence 
at Home physician or Independence at 
Home nurse practitioner; and 
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‘‘(ii) does not have an ownership in-
terest in the Independence at Home orga-
nization unless the Secretary determines 
that it is impracticable to preclude such in-
dividual’s involvement; 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; 
‘‘(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; 
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‘‘(viii) whether, in the professional 
judgment of the individual conducting the 
assessment, the beneficiary is likely to ben-
efit from an Independence at Home pro-
gram; 
‘‘(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; 
‘‘(x) whether the beneficiary has a 
designated primary care physician whom 
the beneficiary has seen in an office-based 
setting within the previous 12 months; and 
‘‘(xi) 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 
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-
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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 services of the participant’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 
‘‘(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-
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tion’ means a provider of services, a physician or 
physician group practice, a nurse practitioner or 
nurse practitioner group practice which receives pay-
ment 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) provides all of the services 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 services in such home or residence, 
has adequate mechanisms for ensuring the pro-
vision of such services by one or more qualified 
entities; 
‘‘(C) has Independence at Home physi-
cians, clinical nurse specialists, nurse practi-
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, as determined 
under the agreement with the Secretary under 
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this section, except to the extent 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 make in-home visits and to be respon-
sible 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-
cine, or the American Board of Physical 
Medicine and Rehabilitation; or 
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‘‘(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. 
‘‘(9) INDEPENDENCE AT HOME NURSE PRACTI-
TIONER.—The term ‘Independence at Home nurse 
practitioner’ means a nurse practitioner who— 
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‘‘(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 make in-home visits and 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-
vided by the American Academy of Nurse 
Practitioners, 
the 
American 
Nurses 
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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 service (or services) provided under an Inde-
pendence 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. 
‘‘(15) 
QUALIFIED
INDIVIDUAL.—The 
term 
‘qualified individual’ means a individual that is li-
censed or otherwise legally permitted to provide the 
specific service (or services) under an Independence 
at Home plan that the individual has agreed to pro-
vide. 
‘‘(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. 
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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. 
‘‘(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, 
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a physician assistant under the supervision of 
an Independence at Home physician and as per-
mitted under State law, or an Independence at 
Home nurse practitioner, and the Independence 
at Home coordinator, develop an Independence 
at Home plan for the participant in accordance 
with paragraph (2); 
‘‘(D) ensure that the participant receives 
an Independence at Home assessment at least 
every 6 months after the original assessment to 
ensure that the Independence at Home plan for 
the participant remains current and appro-
priate; 
‘‘(E) implement all of the services under 
the participant’s Independence at Home plan 
and in instances in which the Independence at 
Home organization does not provide specific 
services within the Independence at Home plan, 
ensure that qualified entities successfully pro-
vide those specific services; and 
‘‘(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-
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nication technologies and mobile diagnostic and 
therapeutic technologies as appropriate and ac-
cepted by the participant. 
‘‘(2) INDEPENDENCE AT HOME PLAN.— 
‘‘(A) IN GENERAL.—An Independence at 
Home plan for a participant shall be developed 
with the participant, an Independence at Home 
physician, a physician assistant under the su-
pervision of an Independence at Home physi-
cian and as permitted under State law, an Inde-
pendence at Home nurse practitioner, or an 
Independence at Home coordinator, and, if ap-
propriate, one or more of the participant’s care-
givers 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 services under 
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 service under 
such plan. 
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‘‘(B) COMMUNICATION OF INDIVIDUALIZED 
INDEPENDENCE AT HOME PLAN TO THE INDE-
PENDENCE AT HOME COORDINATOR.—If the in-
dividual responsible for conducting the partici-
pant’s Independence at Home assessment and 
developing the Independence at Home plan is 
not the participant’s Independence at Home co-
ordinator, the Independence 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 infor-
mation for all of the members of the Independ-
ence at Home care team. 
‘‘(C) SERVICES
PROVIDED
UNDER
AN 
INDEPENDENCE
AT
HOME
PLAN.—An Inde-
pendence at Home organization shall coordinate 
and make available through referral to a quali-
fied entity the services described in the fol-
lowing clauses (i) through (iii) to the extent 
they are needed and covered by under this title 
and shall provide the care coordination services 
described in the following clause (iv) to the ex-
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tent they are appropriate and accepted by a 
participant: 
‘‘(i) Primary care services, such as 
physician visits, diagnosis, treatment, and 
preventive services. 
‘‘(ii) Home health services, such as 
skilled nursing care and physical and occu-
pational therapy. 
‘‘(iii) Phlebotomy and ancillary lab-
oratory and imaging services, including 
point of care laboratory and imaging 
diagnostics. 
‘‘(iv) Care coordination services, con-
sisting of— 
‘‘(I) Monitoring and management 
of medications by a pharmacist who is 
certified in geriatric pharmacy by the 
Commission for Certification in Geri-
atric Pharmacy or possesses other 
comparable 
certification 
dem-
onstrating knowledge and expertise in 
geriatric pharmacotherapy, as well as 
assistance to participants and their 
caregivers with respect to selection of 
a prescription drug plan under part D 
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that best meets the needs of the par-
ticipant’s chronic conditions. 
‘‘(II) Coordination of all medical 
treatment furnished to the partici-
pant, regardless of whether such 
treatment is covered and available to 
the participant under this title. 
‘‘(III) Self-care education and 
preventive care consistent with the 
participant’s condition. 
‘‘(IV) Education for primary 
caregivers and family members. 
‘‘(V) Caregiver counseling serv-
ices and information about, and refer-
ral to, other caregiver support and 
health care services in the community. 
‘‘(VI) Referral to social services, 
such as personal care, meals, volun-
teers, and individual and family ther-
apy. 
‘‘(VII) Information about, and 
access to, hospice care. 
‘‘(VIII) Pain and palliative care 
and end-of-life care, including infor-
mation about developing advanced di-
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rectives and physicians orders for life 
sustaining treatment. 
‘‘(3) PRIMARY TREATMENT ROLE WITHIN AN 
INDEPENDENCE AT HOME CARE TEAM.—An Inde-
pendence at Home physician, a physician assistant 
under the supervision of an Independence at Home 
physician and as permitted under State law, or an 
Independence at Home nurse practitioner may as-
sume 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 provide 
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the Secretary with listings of individuals em-
ployed by the organization, including contract 
employees, and individuals with an ownership 
interest in the organization and comply with 
such additional requirements as the Secretary 
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. 
‘‘(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, program integrity, and 
other requirements as the Secretary deems to 
be appropriate for participants to be served; 
and 
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‘‘(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-
formance standards for Independence at Home 
organizations and programs. 
‘‘(B) STANDARDS
TO
BE
INCLUDED.— 
Such standards shall include measures of— 
‘‘(i) improvement in participant out-
comes; 
‘‘(ii) improvement in satisfaction of 
the beneficiary, caregiver, and provider in-
volved; and 
‘‘(iii) cost savings consistent with 
paragraph (6). 
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‘‘(C) MINIMUM
PARTICIPATION
STAND-
ARD.—Such standards shall include a require-
ment that, for any year after the first year and 
except as the Secretary may provide for a pro-
gram serving a rural area, an Independence at 
Home program had an average number of par-
ticipants 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 by the 
Secretary as necessary to serve the best interest of 
the beneficiaries under this title or the best interest 
of Federal health care programs or upon the request 
of the Independence at Home organization. 
‘‘(5) TERMINATION
AND
NON-RENEWAL
OF 
AGREEMENT.— 
‘‘(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, or if the Sec-
retary deems it necessary to serve the best in-
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terest of the beneficiaries under this title or the 
best interest of Federal health care programs, 
the Secretary may terminate the agreement of 
the organization 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-
fore the end of such year. Paragraphs (6), (8), 
and (9)(B) shall apply to the organization until 
the date of termination. 
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‘‘(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 
made 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) REQUIRED.— 
‘‘(i) IN GENERAL.—Under an agree-
ment under this subsection, each Inde-
pendence at Home organization shall en-
sure 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 partici-
pating beneficiaries, as calculated under 
subparagraph (B), that is not less than 5 
percent of the product described in clause 
(ii) for such participating beneficiaries and 
year. 
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‘‘(ii) 
PRODUCT
DESCRIBED.—The 
product described in this clause for partici-
pating beneficiaries in an Independence at 
Home program for a year is the product 
of— 
‘‘(I) 
the 
estimated 
average 
monthly costs that would have been 
incurred under parts A and B (and, 
to the extent cost information is avail-
able, part 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 
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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. 
‘‘(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, 
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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 
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 30 days before the beginning of 
the first year of the pilot project under this sec-
tion and 120 days before the beginning of any 
Independence at Home program year after the 
first such year, the Secretary shall publish in 
the Federal Register a description of the model 
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developed under subparagraph (B)(i) and infor-
mation for calculating savings required under 
subparagraph (A), including any revisions, suf-
ficient to permit Independence at Home organi-
zations to determine the savings they will be re-
quired to achieve during the program year to 
meet the savings requirement under subpara-
graph (A). In order to facilitate this notice, the 
Secretary may designate a single annual date 
for the beginning of all Independence at Home 
program 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)(2)(C)(iv). 
‘‘(8) ENSURING
MANDATORY
MINIMUM
SAV-
INGS.—The Secretary shall require any Independ-
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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-
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.— 
‘‘(i) 
INITIAL
IMPLEMENTATION 
PHASE.—If an Independence at Home or-
ganization achieves aggregate savings in a 
year in the initial implementation phase in 
excess of the mandatory minimum savings 
described in paragraph (6)(A)(ii), 80 per-
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cent of such aggregate savings shall be 
paid to the organization and the remainder 
shall be retained by the programs under 
this title during the initial implementation 
phase. 
‘‘(ii) 
EXPANDED
IMPLEMENTATION 
PHASE.—If an Independence at Home or-
ganization achieves aggregate savings in a 
year in the expanded implementation phase 
in excess of 5 percent of the product de-
scribed in paragraph (6)(A)(ii)— 
‘‘(I) insofar as such savings do 
not exceed 25 percent of such prod-
uct, 80 percent of such aggregate sav-
ings shall be paid to the organization 
and the remainder shall be retained 
by the programs under this title; and. 
‘‘(II) insofar as such savings ex-
ceed 25 percent of such product, in 
the Secretary’s discretion, 50 percent 
of such excess aggregate savings shall 
be paid to the organization and the 
remainder shall be retained by the 
programs under this title. 
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‘‘(f) 
WAIVER
OF
COINSURANCE
FOR
HOUSE 
CALLS.—A physician, physician assistant, or nurse practi-
tioner furnishing services related to the Independence at 
Home program in the home or residence of a participant 
in an Independence at Home program may waive collec-
tion of any coinsurance that might otherwise be payable 
under section 1833(a) with respect to such services but 
only if the conditions described in section 1128A(i)(6)(A) 
are met. 
‘‘(g) REPORT.—Not later than three months after the 
date of receipt of the independent evaluation provided 
under subsection (a)(5) and each year thereafter during 
which this section is being implemented, the Secretary 
shall submit to the Committees of jurisdiction in Congress 
a report that shall include— 
‘‘(1) whether the Independence at Home pro-
grams under this section are meeting the minimum 
quality and performance standards in (e)(3); 
‘‘(2) a comparative evaluation of Independence 
at Home organizations in order to identify which 
programs, and characteristics of those programs, 
were the most effective in producing the best partici-
pant outcomes, patient and caregiver satisfaction, 
and cost savings; and 
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‘‘(3) an evaluation of whether the participant 
eligibility criteria identified beneficiaries who were in 
the top ten percent of the highest cost Medicare 
beneficiaries.’’. 
(b) CONFORMING AMENDMENT.—Section 1833(a) of 
such Act (42 U.S.C. 1395l(a)) is amended, in the matter 
before paragraph (1), by inserting ‘‘and section 1807A(f)’’ 
after ‘‘section 1876’’. 
Æ 
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