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115th Congress   }                                 {     Rept. 115-446
                        HOUSE OF REPRESENTATIVES
 1st Session     }                                 {            Part 1

======================================================================



 
  INDEPENDENCE AT HOME DEMONSTRATION IMPROVEMENT AND EXTENSION ACT OF 
                                  2017

                                _______
                                

                December 6, 2017.--Ordered to be printed

                                _______
                                

 Mr. Walden, from the Committee on Energy and Commerce, submitted the 
                               following

                              R E P O R T

                        [To accompany H.R. 3263]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Energy and Commerce, to whom was referred 
the bill (H.R. 3263) to amend title XVIII of the Social 
Security Act to extend the Medicare independence at home 
medical practice demonstration program, having considered the 
same, report favorably thereon with an amendment and recommend 
that the bill as amended do pass.

                                CONTENTS

                                                                   Page
Purpose and Summary..............................................     2
Background and Need for Legislation..............................     2
Committee Action.................................................     3
Committee Votes..................................................     3
Oversight Findings and Recommendations...........................     3
New Budget Authority, Entitlement Authority, and Tax Expenditures     3
Congressional Budget Office Estimate.............................     4
Federal Mandates Statement.......................................     6
Statement of General Performance Goals and Objectives............     6
Duplication of Federal Programs..................................     6
Committee Cost Estimate..........................................     6
Earmark, Limited Tax Benefits, and Limited Tariff Benefits.......     6
Disclosure of Directed Rule Makings..............................     6
Advisory Committee Statement.....................................     6
Applicability to Legislative Branch..............................     6
Section-by-Section Analysis of the Legislation...................     7
Changes in Existing Law Made by the Bill, as Reported............     7
Exchange of Letters with Additional Committees of Referral.......    13

    The amendment is as follows:
  Strike all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE.

  This Act may be cited as the ``Independence at Home Demonstration 
Improvement and Extension Act of 2017''.

SEC. 2. EXTENDING THE MEDICARE INDEPENDENCE AT HOME DEMONSTRATION 
                    PROGRAM.

  (a) In General.--Section 1866E of the Social Security Act (42 U.S.C. 
1395cc-5) is amended--
          (1) in subsection (e)--
                  (A) in paragraph (1)--
                          (i) by striking ``An agreement'' and 
                        inserting ``Agreements''; and
                          (ii) by striking ``5-year'' and inserting 
                        ``7-year''; and
                  (B) in paragraph (5)--
                          (i) by striking ``10,000'' and inserting 
                        ``15,000''; and
                          (ii) by adding at the end the following new 
                        sentence: ``An applicable beneficiary that 
                        participates in the demonstration program by 
                        reason of the increase from 10,000 to 15,000 in 
                        the preceding sentence pursuant to the 
                        amendment made by section 2(a)(1)(B) of the 
                        Independence at Home Demonstration Improvement 
                        and Extension Act of 2017 shall be considered 
                        in the spending target estimates under 
                        paragraph (1) of subsection (c) and the 
                        incentive payment calculations under paragraph 
                        (2) of such subsection for the sixth and 
                        seventh years of such program.'';
          (2) in subsection (g), in the first sentence, by inserting 
        ``, including, to the extent practicable, with respect to the 
        use of electronic health information systems, as described in 
        subsection (b)(1)(A)(vi)'' after ``under the demonstration 
        program''; and
          (3) in subsection (i)(1)(A), by striking ``will not receive 
        an incentive payment for the second of 2'' and inserting ``did 
        not achieve savings for the third of 3''.
  (b) Effective Date.--The amendment made by subsection (a)(3) shall 
take effect as if included in the enactment of Public Law 111-148.

                          Purpose and Summary

    H.R. 3263 was introduced on July 17, 2017, by Rep. Michael 
C. Burgess, M.D. (R-TX). H.R. 3263 would extend the 
Independence at Home Medical Practice Demonstration Program 
(IAH), which provides a home-based primary care benefit to 
high-need Medicare beneficiaries with multiple chronic 
conditions. The program is designed to allow beneficiaries to 
stay in their homes instead of institutionalized settings, 
avoiding unnecessary hospitalizations, ER visits, and nursing 
home use. H.R. 3263 would extend the program for two additional 
years.

                  Background and Need for Legislation

    Currently in its fifth year, the Centers for Medicare and 
Medicaid Services (CMS) has evaluated the Independence at Home 
program's success and found it to have saved money for the 
Medicare program in the first and second years (year three data 
is still be analyzed.). Under statute, the demonstration in 
total must generate savings and any practice that does not 
generate savings of 5 percent faces removal from the 
demonstration. With statutory authority for the demonstration 
ending, this extension will provide CMS with additional time to 
evaluate the program's effectiveness and any changes that may 
be needed. The extension will also provide Congress additional 
time and information necessary to weigh the benefits to program 
savings and beneficiary care that the demonstration has brought 
and if the program should be changed, extended or made 
permanent.

                            Committee Action

    On July 20, 2017, the Subcommittee on Health held a hearing 
on H.R. 3263. The hearing was entitled Examining Bipartisan 
Legislation to Improve the Medicare Program. The Subcommittee 
received testimony from:
           Christel Aprigliano, CEO, Diabetes Patient 
        Advocacy Coalition;
           Lisa Bardach, Speech-Language Pathologist, 
        ALS of Michigan;
           K. Eric De Jonge, President-Elect, American 
        Academy of Home Care Medicine (AAHCM);
           Cletis Earle, Chairman-Elect, CHIME Board of 
        Trustees;
           Mary Grealy, President, Healthcare 
        Leadership Council;
           Deepak A. Kapoor, Chairman and CEO, 
        Integrated Medical Professionals;
           Brett Kissela, Chair, Department of 
        Neurology and Rehabilitation Medicine, University of 
        Cincinnati Gardner Neuroscience Institute, on behalf of 
        American Academy of Neurology;
           Justin Moore, CEO, American Physical Therapy 
        Association;
           Alan E. Morrison, Chair, Diagnostic Services 
        Committee, National Association for the Support of Long 
        Term Care (NASL);
           Varner Richards, Board Chair, National Home 
        Infusion Association; and
           Stacy Sanders, Federal Policy Director, 
        Medicare Rights Center.
    On September 13, 2017, the Subcommittee on Health met in 
open markup session and forwarded H.R. 3263, without amendment, 
to the full Committee by a voice vote. On October 4, 2017, the 
full Committee on Energy and Commerce met in open markup 
session and ordered H.R. 3263, as amended, favorably reported 
to the House by a voice vote.

                            Committee Votes

    Clause 3(b) of rule XIII requires the Committee to list the 
record votes on the motion to report legislation and amendments 
thereto. There were no record votes taken in connection with 
ordering H.R. 3263 reported.

                 Oversight Findings and Recommendations

    Pursuant to clause 2(b)(1) of rule X and clause 3(c)(1) of 
rule XIII, the Committee held a hearing and made findings that 
are reflected in this report.

   New Budget Authority, Entitlement Authority, and Tax Expenditures

    Pursuant to clause 3(c)(2) of rule XIII, the Committee 
finds that H.R. 3263 would result in no new or increased budget 
authority, entitlement authority, or tax expenditures or 
revenues.

                  Congressional Budget Office Estimate

    Pursuant to clause 3(c)(3) of rule XIII, the following is 
the cost estimate provided by the Congressional Budget Office 
pursuant to section 402 of the Congressional Budget Act of 
1974:

H.R. 3263--A bill to amend title XVIII of the Social Security Act to 
        extend the Medicare Independence at Home Medical Practice 
        Demonstration program

    Summary: H.R. 3263 would extend the Independence at Home 
(IAH) program for two years, through late fiscal year 2019, and 
would increase the aggregate cap on the number of Medicare 
beneficiaries served by participating providers from 10,000 to 
15,000. CBO estimates that enacting H.R. 3263 would increase 
direct spending by $16 million over the 2018-2027 period.
    Enacting H.R. 3263 would affect direct spending; therefore, 
pay-as-you-go procedures apply. The legislation would not 
affect revenues.
    CBO estimates that enacting H.R. 3263 would not increase 
net direct spending or on-budget deficits by more than $5 
billion in one or more of the four consecutive 10-year periods 
beginning in 2028.
    H.R. 3263 contains no intergovernmental or private sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
    Estimated cost to the Federal Government: The estimated 
budgetary effect of H.R. 3263 is shown in the following table. 
The costs of this legislation fall within budget function 570 
(Medicare).

--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                  By fiscal year, in millions of dollars--
                                                   -----------------------------------------------------------------------------------------------------
                                                     2018    2019    2020    2021    2022    2023    2024    2025    2026    2027   2018-2022  2018-2027
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                              INCREASES IN DIRECT SPENDING
 
Estimated Budget Authority........................       0       2       7       7       0       0       0       0       0       0        16         16
Estimated Outlays.................................       0       2       7       7       0       0       0       0       0       0        16         16
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Basis of estimate: Primary care services provided in a 
number of settings, including a patient's home, are covered by 
the Medicare program. The IAH program was established to test 
whether providing a financial incentive--bonus payments--for 
providers to deliver primary care services in a patient's home 
would reduce Medicare spending and improve the quality of care. 
Providers participating in the IAH program receive a bonus 
payment if their practice meets quality standards and the 
average cost of Medicare benefits for its patients is less than 
95 percent of the average cost of such benefits for similar 
patients in the community.\1\
---------------------------------------------------------------------------
    \1\Measuring the cost of similar patients in the community has 
proved to be a very difficult technical challenge. As a result, each 
time the evaluators have analyzed the data for a performance year, they 
have recommended making substantial changes to how those costs will be 
estimated for a subsequent performance year. Participating providers 
have been given the choice of continuing to use the existing method or 
switching to the newly developed method.
---------------------------------------------------------------------------
    Those bonus payments would add to federal costs. The 
ultimate budgetary effect would depend on whether they resulted 
in offsetting reductions in Medicare spending. However, 
determining that the patients served by participating providers 
have Medicare costs that, on average, are below that 95 percent 
level does not necessarily indicate that the IAH program 
reduces Medicare spending, because it does not indicate that 
the program has changed Medicare's costs for beneficiaries 
served by participating providers. Expanding the use of home-
based services through the IAH program would probably increase 
the use of certain services, but would ultimately reduce 
Medicare spending if the resulting change in practice patterns 
lowered health care costs or if the IAH program shifted market 
share from higher-cost to lower-cost providers, as long as the 
resulting savings amounted to more than the bonuses paid 
through the program. To date, interim evaluations of the IAH 
program have not assessed whether such changes have occurred. 
In the absence of such information, CBO has no basis for 
concluding whether the bonus payments offered through the IAH 
program have spurred participating providers to make changes 
affecting Medicare spending.
    Further, the bonus payments, as designed, are not targeted 
exclusively at inducing changes to reduce spending. Instead, 
providers with relatively low costs would qualify for bonuses 
whether they make any changes in the way they provide care or 
not. Similarly, providers who do make changes, but do not lower 
spending by enough to qualify for a bonus would not receive 
one. On the basis of the bonus payments made to date, CBO 
estimates that Medicare would make annual bonus payments to 
participating providers that average about $5 million per 
10,000 beneficiaries for each additional year of the 
demonstration. Taking into account both the 5,000 increase in 
the cap on the number of participating beneficiaries and the 
effect of interactions between changes in spending in the fee-
for-service sector and payment rates in the Medicare Advantage 
(MA) program, CBO estimates that the bill's changes to the IAH 
program would increase Medicare spending by $16 million over 
the 2018-2027 period.
    Pay-As-You-Go Considerations: The Statutory Pay-As-You-Go 
Act of 2010 establishes budget-reporting and enforcement 
procedures for legislation affecting direct spending or 
revenues. The net changes in outlays that are subject to those 
pay-as-you-go procedures are shown in the following table.

        CBO ESTIMATE OF PAY-AS-YOU-GO EFFECTS FOR H.R. 3263, AS ORDERED REPORTED BY THE HOUSE COMMITTEE ON ENERGY AND COMMERCE ON OCTOBER 4, 2017
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                  By fiscal year, in millions of dollars--
                                                   -----------------------------------------------------------------------------------------------------
                                                     2018    2019    2020    2021    2022    2023    2024    2025    2026    2027   2018-2022  2018-2027
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                               NET INCREASE IN THE DEFICIT
Statutory Pay-As-You-Go Impact....................       0       2       7       7       0       0       0       0       0       0        16         16
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Increase in long-term direct spending and deficits: CBO 
estimates that enacting the legislation would not increase net 
direct spending or on-budget deficits by more than $5 billion 
in any of the four consecutive 10-year periods beginning in 
2028.
    Intergovernmental and private-sector impact: H.R. 3263 
contains no intergovernmental or private-sector mandates as 
defined in UMRA.
    Previous CBO estimate: On August 1, 2017, CBO produced an 
estimate for S. 870, the Creating High-Quality Results and 
Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 
2017, as ordered reported by the Senate Committee on Finance on 
May 18, 2017. The provisions in S. 870 extending the 
Independence at Home program are identical to H.R. 3263 and 
CBO's estimate of their budgetary effects is the same.
    Estimate prepared by: Federal Costs: Colin Yee; Impact on 
State, Local, and Tribal Governments and the Private Sector: 
Amy Petz.
    Estimate approved by: Theresa Gullo, Assistant Director for 
Budget Analysis

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates prepared by the Director of the Congressional Budget 
Office pursuant to section 423 of the Unfunded Mandates Reform 
Act.

         Statement of General Performance Goals and Objectives

    Pursuant to clause 3(c)(4) of rule XIII, the general 
performance goal or objective of this legislation is to extend 
the Independence at Home Medical Practice Demonstration 
Program.

                    Duplication of Federal Programs

    Pursuant to clause 3(c)(5) of rule XIII, no provision of 
H.R. 3263 is known to be duplicative of another Federal 
program, including any program that was included in a report to 
Congress pursuant to section 21 of Public Law 111-139 or the 
most recent Catalog of Federal Domestic Assistance.

                        Committee Cost Estimate

    Pursuant to clause 3(d)(1) of rule XIII, the Committee 
adopts as its own the cost estimate prepared by the Director of 
the Congressional Budget Office pursuant to section 402 of the 
Congressional Budget Act of 1974.

       Earmark, Limited Tax Benefits, and Limited Tariff Benefits

    Pursuant to clause 9(e), 9(f), and 9(g) of rule XXI, the 
Committee finds that H.R. 3263 contains no earmarks, limited 
tax benefits, or limited tariff benefits.

                  Disclosure of Directed Rule Makings

    Pursuant to section 3(i) of H.Res. 5, the Committee finds 
that H.R. 3263 contains no directed rule makings.

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act were created by this 
legislation.

                  Applicability to Legislative Branch

    The Committee finds that the legislation does not relate to 
the terms and conditions of employment or access to public 
services or accommodations within the meaning of section 
102(b)(3) of the Congressional Accountability Act.

             Section-by-Section Analysis of the Legislation


Section 1. Short title

    Section 1 provides that the Act may be cited as the 
``Independence at Home Demonstration Improvement and Extension 
act of 2017.''

Section 2. Extending the Medicare Independence at Home Demonstration 
        Program

    Section 2 would extend the Medicare Independence at Home 
Demonstration Program for two additional years and raise the 
limit on the number of practices allowed to participate in the 
demonstration program from 10,000 to 15,000. In addition, the 
section would expand the scope of the required evaluation and 
report to Congress to include an evaluation of the use of 
electronic health information systems. Finally, the section 
would change the conditions under which the Department of 
Health and Human Services (HHS) must terminate an agreement 
with an independent at home medical practice to require HHS to 
terminate such an agreement if it did not achieve savings for 
three consecutive years.

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, and existing law in which no 
change is proposed is shown in roman):

                          SOCIAL SECURITY ACT




           *       *       *       *       *       *       *
TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED

           *       *       *       *       *       *       *



Part E--Miscellaneous Provisions

           *       *       *       *       *       *       *



      independence at home medical practice demonstration program

  Sec. 1866E. (a) Establishment.--
          (1) In general.--The Secretary shall conduct a 
        demonstration program (in this section referred to as 
        the ``demonstration program'') to test a payment 
        incentive and service delivery 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 beneficiaries 
        (as defined in subsection (d)).
          (2) Requirement.--The demonstration program shall 
        test whether a model described in paragraph (1), which 
        is accountable for providing comprehensive, 
        coordinated, continuous, and accessible care to high-
        need populations at home and coordinating health care 
        across all treatment settings, results in--
                  (A) reducing preventable hospitalizations;
                  (B) preventing hospital readmissions;
                  (C) reducing emergency room visits;
                  (D) improving health outcomes commensurate 
                with the beneficiaries' stage of chronic 
                illness;
                  (E) improving the efficiency of care, such as 
                by reducing duplicative diagnostic and 
                laboratory tests;
                  (F) reducing the cost of health care services 
                covered under this title; and
                  (G) achieving beneficiary and family 
                caregiver satisfaction.
  (b) Independence at Home Medical Practice.--
          (1) Independence at home medical practice defined.--
        In this section:
                  (A) In general.--The term ``independence at 
                home medical practice'' means a legal entity 
                that--
                          (i) is comprised of an individual 
                        physician or nurse practitioner or 
                        group of physicians and nurse 
                        practitioners that provides care as 
                        part of a team that includes 
                        physicians, nurses, physician 
                        assistants, pharmacists, and other 
                        health and social services staff as 
                        appropriate who have experience 
                        providing home-based primary care to 
                        applicable beneficiaries, make in-home 
                        visits, and are available 24 hours per 
                        day, 7 days per week to carry out plans 
                        of care that are tailored to the 
                        individual beneficiary's chronic 
                        conditions and designed to achieve the 
                        results in subsection (a);
                          (ii) is organized at least in part 
                        for the purpose of providing 
                        physicians' services;
                          (iii) has documented experience in 
                        providing home-based primary care 
                        services to high-cost chronically ill 
                        beneficiaries, as determined 
                        appropriate by the Secretary;
                          (iv) furnishes services to at least 
                        200 applicable beneficiaries (as 
                        defined in subsection (d)) during each 
                        year of the demonstration program;
                          (v) has entered into an agreement 
                        with the Secretary;
                          (vi) uses electronic health 
                        information systems, remote monitoring, 
                        and mobile diagnostic technology; and
                          (vii) meets such other criteria as 
                        the Secretary determines to be 
                        appropriate to participate in the 
                        demonstration program.
                The entity shall report on quality measures (in 
                such form, manner, and frequency as specified 
                by the Secretary, which may be for the group, 
                for providers of services and suppliers, or 
                both) and report to the Secretary (in a form, 
                manner, and frequency as specified by the 
                Secretary) such data as the Secretary 
                determines appropriate to monitor and evaluate 
                the demonstration program.
                  (B) Physician.--The term ``physician'' 
                includes, except as the Secretary may otherwise 
                provide, any individual who furnishes services 
                for which payment may be made as physicians' 
                services and has the medical training or 
                experience to fulfill the physician's role 
                described in subparagraph (A)(i).
          (2) Participation of nurse practitioners and 
        physician assistants.--Nothing in this section shall be 
        construed to prevent a nurse practitioner or physician 
        assistant from participating in, or leading, a home-
        based primary care team as part of an independence at 
        home medical practice if--
                  (A) all the requirements of this section are 
                met;
                  (B) the nurse practitioner or physician 
                assistant, as the case may be, is acting 
                consistent with State law; and
                  (C) the nurse practitioner or physician 
                assistant has the medical training or 
                experience to fulfill the nurse practitioner or 
                physician assistant role described in paragraph 
                (1)(A)(i).
          (3) Inclusion of providers and practitioners.--
        Nothing in this subsection shall be construed as 
        preventing an independence at home medical practice 
        from including a provider of services or a 
        participating practitioner described in section 
        1842(b)(18)(C) that is affiliated with the practice 
        under an arrangement structured so that such provider 
        of services or practitioner participates in the 
        demonstration program and shares in any savings under 
        the demonstration program.
          (4) Quality and performance standards.--The Secretary 
        shall develop quality performance standards for 
        independence at home medical practices participating in 
        the demonstration program.
  (c) Payment Methodology.--
          (1) Establishment of target spending level.--The 
        Secretary shall establish an estimated annual spending 
        target, for the amount the Secretary estimates would 
        have been spent in the absence of the demonstration, 
        for items and services covered under parts A and B 
        furnished to applicable beneficiaries for each 
        qualifying independence at home medical practice under 
        this section. Such spending targets shall be determined 
        on a per capita basis. Such spending targets shall 
        include a risk corridor that takes into account normal 
        variation in expenditures for items and services 
        covered under parts A and B furnished to such 
        beneficiaries with the size of the corridor being 
        related to the number of applicable beneficiaries 
        furnished services by each independence at home medical 
        practice. The spending targets may also be adjusted for 
        other factors as the Secretary determines appropriate.
          (2) Incentive payments.--Subject to performance on 
        quality measures, a qualifying independence at home 
        medical practice is eligible to receive an incentive 
        payment under this section if actual expenditures for a 
        year for the applicable beneficiaries it enrolls are 
        less than the estimated spending target established 
        under paragraph (1) for such year. An incentive payment 
        for such year shall be equal to a portion (as 
        determined by the Secretary) of the amount by which 
        actual expenditures (including incentive payments under 
        this paragraph) for applicable beneficiaries under 
        parts A and B for such year are estimated to be less 
        than 5 percent less than the estimated spending target 
        for such year, as determined under paragraph (1).
  (d) Applicable Beneficiaries.--
          (1) Definition.--In this section, the term 
        ``applicable beneficiary'' means, with respect to a 
        qualifying independence at home medical practice, an 
        individual who the practice has determined--
                  (A) is entitled to benefits under part A and 
                enrolled for benefits under part B;
                  (B) is not enrolled in a Medicare Advantage 
                plan under part C or a PACE program under 
                section 1894;
                  (C) has 2 or more chronic illnesses, such as 
                congestive heart failure, diabetes, other 
                dementias designated by the Secretary, chronic 
                obstructive pulmonary disease, ischemic heart 
                disease, stroke, Alzheimer's Disease and 
                neurodegenerative diseases, and other diseases 
                and conditions designated by the Secretary 
                which result in high costs under this title;
                  (D) within the past 12 months has had a 
                nonelective hospital admission;
                  (E) within the past 12 months has received 
                acute or subacute rehabilitation services;
                  (F) has 2 or more functional dependencies 
                requiring the assistance of another person 
                (such as bathing, dressing, toileting, walking, 
                or feeding); and
                  (G) meets such other criteria as the 
                Secretary determines appropriate.
          (2) Patient election to participate.--The Secretary 
        shall determine an appropriate method of ensuring that 
        applicable beneficiaries have agreed to enroll in an 
        independence at home medical practice under the 
        demonstration program. Enrollment in the demonstration 
        program shall be voluntary.
          (3) Beneficiary access to services.--Nothing in this 
        section shall be construed as encouraging physicians or 
        nurse practitioners to limit applicable beneficiary 
        access to services covered under this title and 
        applicable beneficiaries shall not be required to 
        relinquish access to any benefit under this title as a 
        condition of receiving services from an independence at 
        home medical practice.
  (e) Implementation.--
          (1) Starting date.--The demonstration program shall 
        begin no later than January 1, 2012. [An agreement] 
        Agreements with an independence at home medical 
        practice under the demonstration program may cover not 
        more than a [5-year] 7-year period.
          (2) No physician duplication in demonstration 
        participation.--The Secretary shall not pay an 
        independence at home medical practice under this 
        section that participates in section 1899.
          (3) No beneficiary duplication in demonstration 
        participation.--The Secretary shall ensure that no 
        applicable beneficiary enrolled in an independence at 
        home medical practice under this section is 
        participating in the programs under section 1899.
          (4) Preference.--In approving an independence at home 
        medical practice, the Secretary shall give preference 
        to practices that are--
                  (A) located in high-cost areas of the 
                country;
                  (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.
          (5) Limitation on number of practices.--In selecting 
        qualified independence at home medical practices to 
        participate under the demonstration program, the 
        Secretary shall limit the number of such practices so 
        that the number of applicable beneficiaries that may 
        participate in the demonstration program does not 
        exceed [10,000] 15,000 An applicable beneficiary that 
        participates in the demonstration program by reason of 
        the increase from 10,000 to 15,000 in the preceding 
        sentence pursuant to the amendment made by section 
        2(a)(1)(B) of the Independence at Home Demonstration 
        Improvement and Extension Act of 2017 shall be 
        considered in the spending target estimates under 
        paragraph (1) of subsection (c) and the incentive 
        payment calculations under paragraph (2) of such 
        subsection for the sixth and seventh years of such 
        program.
          (6) Waiver.--The Secretary may waive such provisions 
        of this title and title XI as the Secretary determines 
        necessary in order to implement the demonstration 
        program.
          (7) Administration.--Chapter 35 of title 44, United 
        States Code, shall not apply to this section.
  (f) Evaluation and Monitoring.--
          (1) In general.--The Secretary shall evaluate each 
        independence at home medical practice under the 
        demonstration program to assess whether the practice 
        achieved the results described in subsection (a).
          (2) Monitoring applicable beneficiaries.--The 
        Secretary may monitor data on expenditures and quality 
        of services under this title after an applicable 
        beneficiary discontinues receiving services under this 
        title through a qualifying independence at home medical 
        practice.
  (g) Reports to Congress.--The Secretary shall conduct an 
independent evaluation of the demonstration program and submit 
to Congress a final report, including best practices under the 
demonstration program, including, to the extent practicable, 
with respect to the use of electronic health information 
systems, as described in subsection (b)(1)(A)(vi). Such report 
shall include an analysis of the demonstration program on 
coordination of care, expenditures under this title, applicable 
beneficiary access to services, and the quality of health care 
services provided to applicable beneficiaries.
  (h) Funding.--For purposes of administering and carrying out 
the demonstration program, other than for payments for items 
and services furnished under this title and incentive payments 
under subsection (c), in addition to funds otherwise 
appropriated, there shall be transferred to the Secretary for 
the Center for Medicare & Medicaid Services Program Management 
Account from the Federal Hospital Insurance Trust Fund under 
section 1817 and the Federal Supplementary Medical Insurance 
Trust Fund under section 1841 (in proportions determined 
appropriate by the Secretary) $5,000,000 for each of fiscal 
years 2010 through 2015. Amounts transferred under this 
subsection for a fiscal year shall be available until expended.
  (i) Termination.--
          (1) Mandatory termination.--The Secretary shall 
        terminate an agreement with an independence at home 
        medical practice if--
                  (A) the Secretary estimates or determines 
                that such practice [will not receive an 
                incentive payment for the second of 2] did not 
                achieve savings for the third of 3 consecutive 
                years under the demonstration program; or
                  (B) such practice fails to meet quality 
                standards during any year of the demonstration 
                program.
          (2) Permissive termination.--The Secretary may 
        terminate an agreement with an independence at home 
        medical practice for such other reasons determined 
        appropriate by the Secretary.

           *       *       *       *       *       *       *

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