H. Rept. 115-446 - INDEPENDENCE AT HOME DEMONSTRATION IMPROVEMENT AND EXTENSION ACT OF 2017115th Congress (2017-2018)
Committee Report
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115th Congress } { Rept. 115-446
HOUSE OF REPRESENTATIVES
1st Session } { Part 1
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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).
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By fiscal year, in millions of dollars--
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2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2018-2022 2018-2027
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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
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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.
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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
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By fiscal year, in millions of dollars--
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2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2018-2022 2018-2027
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NET INCREASE IN THE DEFICIT
Statutory Pay-As-You-Go Impact.................... 0 2 7 7 0 0 0 0 0 0 16 16
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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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