II 

109TH CONGRESS 

1ST SESSION S. 1001 

To establish hospice demonstration projects and a hospice grant program 

for beneficiaries under the medicare program under title XVIII of the 

Social Security Act, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

MAY 11, 2005 

Mr. WYDEN introduced the following bill; which was read twice and referred 

to the Committee on Finance 

A BILL 

To establish hospice demonstration projects and a hospice 

grant program for beneficiaries under the medicare program under title XVIII of the Social Security Act, and 

for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Medicare Hospice 

5 Demonstration Act of 2005’’. 

6 SEC. 2. FINDINGS. 

7 Congress makes the following findings: 
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(1) Each year more than 1 1 ⁄3 of the people who 

2 die suffer from a chronic illness. 

(2) Approximately 1 3 ⁄3 of Americans are unsure 

4 about whom to contact to get the best care during 

5 life’s last stages. 

6 (3) Americans want a team of professionals to 

7 care for the patient at the end of life. 

8 (4) Americans want emotional and spiritual 

9 support for the patient and family. 

10 (5) Ninety percent of Americans do not realize 

11 that hospice care is a benefit provided under the 

12 medicare program under title XVIII of the Social 

13 Security Act. 

14 (6) Data of the Centers for Medicare & Med15 icaid Services show that beneficiaries were enrolled 

16 in hospice for an average of less than 7 weeks in 

17 1998, far less than the full 6-month benefit under 

18 the medicare program. 

19 (7) According to the most recent data available, 

20 although more medicare beneficiaries are enrolled in 

21 hospice, the medicare length of stay has declined. 

22 (8) Use of hospice among medicare beneficiaries 

23 has been decreasing, from a high of 59 days in 1995 

24 to less than 48 days in 1998. 
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1 SEC. 3. HOSPICE DEMONSTRATION PROJECTS AND HOS2 PICE EDUCATION GRANTS. 

3 (a) DEFINITIONS.—In this section: 

4 (1) DEMONSTRATION PROJECT.—The term 

5 ‘‘demonstration project’’ means a demonstration 

6 project established by the Secretary under sub7 section (b)(1). 

8 (2) HOSPICE CARE.—The term ‘‘hospice care’’ 

9 means the items and services described in subpara10 graphs (A) through (I) of section 1861(dd)(1) of the 

11 Social Security Act (42 U.S.C. 1395x(dd)(1)) that 

12 are provided to a seriously ill medicare beneficiary 

13 under a demonstration project by a hospice program 

14 (or by others under an arrangement with such a 

15 program) under a written plan for providing such 

16 care to such beneficiary established and periodically 

17 reviewed by the beneficiary’s attending physician, by 

18 the medical director of the program, and by the 

19 interdisciplinary group described in section 

20 1861(dd)(2)(B) of such Act (42 U.S.C. 

21 1395x(dd)(2)(B)). 

22 (3) HOSPICE PROGRAM.—The term ‘‘hospice 

23 program’’ has the meaning given that term in sec24 tion 1861(dd)(2) of the Social Security Act (42 

25 U.S.C. 1395x(dd)(2)). 
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1 (4) MEDICARE BENEFICIARY.—The term 

2 ‘‘medicare beneficiary’’ means any individual who is 

3 entitled to benefits under part A or enrolled under 

4 part B of the medicare program. 

5 (5) MEDICARE PROGRAM.—The term ‘‘medicare 

6 program’’ means the health benefits program under 

7 title XVIII of the Social Security Act (42 U.S.C. 

8 1395 et seq.). 

9 (6) SECRETARY.—The term ‘‘Secretary’’ means 

10 the Secretary of Health and Human Services. 

11 (7) SERIOUSLY ILL.—The term ‘‘seriously ill’’ 

12 has the meaning given such term by the Secretary 

13 (in consultation with hospice programs and academic 

14 experts in end-of-life care), except that the Secretary 

15 may not limit such term to individuals who are ter16 minally ill (as defined in section 1861(dd)(3)(A) of 

17 the Social Security Act (42 U.S.C. 

18 1395x(dd)(3)(A))). 

19 (b) HOSPICE DEMONSTRATION PROJECTS.— 

20 (1) ESTABLISHMENT.—The Secretary shall es21 tablish demonstration projects in accordance with 

22 the provisions of this subsection to increase the util23 ity of the hospice care for seriously ill medicare 

24 beneficiaries. 

25 (2) PARTICIPATION.— 
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1 (A) HOSPICE PROGRAMS.—Except as pro2 vided in paragraph (4)(A), only a hospice pro3 gram with an agreement under section 1866 of 

4 the Social Security Act (42 U.S.C. 1395cc), a 

5 consortium of such hospice programs, or a 

6 State hospice association may participate in the 

7 demonstration program. 

8 (B) SERIOUSLY ILL MEDICARE BENE9 FICIARIES.—The Secretary shall permit any se10 riously ill medicare beneficiary residing in the 

11 service area of a hospice program participating 

12 in a demonstration project to participate in 

13 such project on a voluntary basis. 

14 (3) SERVICES UNDER DEMONSTRATION

15 PROJECTS.—The provisions of section 1814(i) of the 

16 Social Security Act (42 U.S.C. 1395f(i)) shall apply 

17 to the payment for hospice care provided under the 

18 demonstration projects, except that— 

19 (A) notwithstanding section 1862(a)(1)(C) 

20 of such Act (42 U.S.C. 1395y(a)(1)(C)), the 

21 Secretary shall provide for reimbursement for 

22 items and services provided under the sup23 portive and comfort care benefit established 

24 under paragraph (3); 
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1 (B) any licensed nurse practitioner or phy2 sician assistant may admit a seriously ill medi3 care beneficiary as the primary care provider 

4 when necessary and within the scope of practice 

5 of such practitioner or assistant under State 

6 law; 

7 (C) if an underserved community included 

8 in a demonstration project does not have a 

9 qualified social worker, any professional (other 

10 than a social worker) who has the necessary 

11 knowledge, skills, and ability to provide medical 

12 social services may provide such services; 

13 (D) the Secretary shall waive any require14 ment that nursing facilities used for respite 

15 care have skilled nurses on the premises 24 

16 hours per day; 

17 (E) the Secretary shall permit respite care 

18 to be provided to the seriously ill medicare ben19 eficiary at home; and 

20 (F) the Secretary shall waive reimburse21 ment regulations to provide— 

22 (i) reimbursement for consultations 

23 and preadmission informational visits, even 

24 if the seriously ill medicare beneficiary 

25 does not elect hospice care at that time; 
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1 (ii) except with respect to the sup2 portive and comfort care benefit under 

3 paragraph (3), a minimum payment for 

4 hospice care provided under the dem5 onstration projects based on the provision 

6 of hospice care to a seriously ill medicare 

7 beneficiary for a period of 14 days, that— 

8 (I) the Secretary shall pay to any 

9 hospice program participating in a 

10 demonstration project and providing 

11 such care (regardless of the length of 

12 stay of the seriously ill medicare bene13 ficiary); and 

14 (II) may not be less than the 

15 amount of payment that would have 

16 been made for hospice care if payment 

17 had been made at the daily rate of 

18 payment for such care under section 

19 1814(i) of the Social Security Act (42 

20 U.S.C. 1395f(i)); 

21 (iii) an increase in the reimbursement 

22 rates for hospice care to offset— 

23 (I) changes in hospice care and 

24 oversight under the demonstration 

25 projects; 
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1 (II) the higher costs of providing 

2 hospice care in rural areas due to lack 

3 of economies of scale or large geo4 graphic areas; and 

5 (III) the higher costs of pro6 viding hospice care in urban under7 served areas due to unique costs spe8 cifically associated with people living 

9 in those areas, including providing se10 curity; 

11 (iv) direct payment of any nurse prac12 titioner or physician assistant practicing 

13 within the scope of State law in relation to 

14 hospice care provided by such practitioner 

15 or assistant; and 

16 (v) a per diem rate of payment for in17 home care under subparagraph (E) that 

18 reflects the range of care needs of the seri19 ously ill medicare beneficiary and that— 

20 (I) in the case of a seriously ill 

21 medicare beneficiary that needs rou22 tine care, is not less than 150 percent, 

23 and not more than 200 percent, of the 

24 routine home care rate for hospice 

25 care; and 
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1 (II) in the case of a seriously ill 

2 medicare beneficiary that needs acute 

3 care, is equal to the continuous home 

4 care day rate for hospice care. 

5 (4) SUPPORTIVE AND COMFORT CARE BEN6 EFIT.— 

7 (A) IN GENERAL.—For purposes of the 

8 demonstration projects, the Secretary shall es9 tablish a supportive and comfort care benefit 

10 for any eligible seriously ill medicare beneficiary 

11 (as defined in subparagraph (C)). 

12 (B) PARTICIPATION.—Any individual or 

13 entity with an agreement under section 1866 of 

14 the Social Security Act (42 U.S.C. 1395cc) may 

15 furnish items or services covered under the sup16 portive and comfort care benefit. 

17 (C) BENEFIT.—Under the supportive and 

18 comfort care benefit, any eligible seriously ill 

19 medicare beneficiary may— 

20 (i) continue to receive benefits for dis21 ease and symptom modifying treatment 

22 under the medicare program (and the Sec23 retary may not require or prohibit any spe24 cific treatment or decision); 
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1 (ii) receive case management and hos2 pice care through a hospice program par3 ticipating in a demonstration project (for 

4 which payment shall be made under para5 graph (2)(F)(ii)); and 

6 (iii) receive information and education 

7 in order to better understand the utility of 

8 hospice care. 

9 (D) PAYMENT.—The Secretary shall estab10 lish procedures under which the Secretary pays 

11 for items and services furnished to seriously ill 

12 medicare beneficiaries under the supportive and 

13 comfort care benefit on a fee-for-service basis. 

14 (E) ELIGIBLE SERIOUSLY ILL MEDICARE

15 BENEFICIARY DEFINED.— 

16 (i) IN GENERAL.—In this paragraph, 

17 the term ‘‘eligible seriously ill medicare 

18 beneficiary’’ means any seriously ill medi19 care beneficiary that meets the criteria ap20 proved by the Secretary under clause (ii). 

21 (ii) APPROVAL OF CRITERIA.— 

22 (I) IN GENERAL.—With respect 

23 to each demonstration project, the 

24 Secretary shall approve criteria for 

25 determining whether a seriously ill 
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1 medicare beneficiary is eligible for 

2 hospice care under a demonstration 

3 project that has been developed by 

4 hospice programs in consultation with 

5 researchers in end-of-life care and the 

6 broader medical community. 

7 (II) DATA COMPARABILITY.—The 

8 Secretary may only approve criteria 

9 that ensures that each demonstration 

10 project yields comparable data with 

11 respect to eligible seriously ill medi12 care beneficiaries on— 

13 (aa) the utilization of serv14 ices by such beneficiaries; 

15 (bb) the cost of providing 

16 services to such beneficiaries, in17 cluding any costs associated with 

18 providing services before an indi19 vidual is terminally ill (as defined 

20 in section 1861(dd)(3)(A) of the 

21 Social Security Act (42 U.S.C. 

22 1395x(dd)(3)(A))); and 

23 (cc) the effect of the dem24 onstration project on the quality 

25 of care of such beneficiaries. 
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1 (III) LIMITATION.—The Sec2 retary may not approve criteria if the 

3 purpose of such criteria is to segment 

4 services or to provide a benefit for the 

5 chronically ill. 

6 (5) CONDUCT OF DEMONSTRATION

7 PROJECTS.— 

8 (A) SITES.—The Secretary shall conduct 

9 demonstration projects in at least 3, but not 

10 more than 6, sites (which may be statewide). 

11 (B) SELECTION OF SITES.— 

12 (i) IN GENERAL.—Except as provided 

13 in clause (ii), the Secretary shall select 

14 demonstration sites on the basis of pro15 posals submitted under subparagraph (C) 

16 that are located in geographic areas that— 

17 (I) include both urban and rural 

18 hospice programs; and 

19 (II) are geographically diverse 

20 and readily accessible to a significant 

21 number of seriously ill medicare bene22 ficiaries. 

23 (ii) EXCEPTIONS.— 

24 (I) UNDERSERVED URBAN

25 AREAS.—If a geographic area does 
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1 not have any rural hospice program 

2 available to participate in a dem3 onstration project, such area may sub4 stitute an underserved urban area, 

5 but the Secretary shall give priority to 

6 those proposals that include a rural 

7 hospice program. 

8 (II) SPECIFIC SITE.—The Sec9 retary shall select as a demonstration 

10 site the State in which (according to 

11 the Hospital Referral Region of Resi12 dence, 1994–1995, as listed in the 

13 Dartmouth Atlas of Health Care 

14 1998) the largest metropolitan area of 

15 the State had the lowest percentage of 

16 medicare beneficiary deaths in a hos17 pital when compared to the largest 

18 metropolitan area of each other State, 

19 and the percentage of enrollees who 

20 experienced intensive care during the 

21 last 6 months of life was 21.5 percent. 

22 (C) PROPOSALS.— 

23 (i) IN GENERAL.—The Secretary shall 

24 accept proposals by any State hospice asso25 ciation, hospice program, or consortium of 
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1 hospice programs at such time, in such 

2 manner, and in such form as the Secretary 

3 may reasonably require. 

4 (ii) RESEARCH DESIGNS.—The Sec5 retary shall permit research designs that 

6 use time series, sequential implementation 

7 of the intervention, randomization by wait 

8 list, and other designs that allow the 

9 strongest possible implementation of the 

10 demonstration projects, while still allowing 

11 strong evaluation about the merits of the 

12 demonstration projects. 

13 (D) FACILITATION OF EVALUATION.—The 

14 Secretary shall design the program to facilitate 

15 the evaluation conducted under paragraph (7). 

16 (6) DURATION.—The Secretary shall complete 

the demonstration projects within a period of 61 17 ⁄2

18 years that includes a period of 18 months during 

19 which the Secretary shall complete the evaluation 

20 under paragraph (7). 

21 (7) EVALUATION.—During the 18-month period 

22 following the first 5 years of the demonstration 

23 projects, the Secretary shall complete an evaluation 

24 of the demonstration projects in order to deter25 mine— 
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1 (A) the short-term and long-term costs and 

2 benefits of changing hospice care provided 

3 under the medicare program to include the 

4 items, services, and reimbursement options pro5 vided under the demonstration projects; 

6 (B) whether any increase in payments for 

7 the hospice care provided under the medicare 

8 program are offset by savings in other parts of 

9 the medicare program; 

10 (C) the projected cost of implementing the 

11 demonstration projects on a national basis; and 

12 (D) in consultation with hospice organiza13 tions and hospice programs (including organiza14 tions and providers that represent rural areas), 

15 whether a payment system based on diagnosis16 related groups is useful for administering the 

17 hospice care provided under the medicare pro18 gram. 

19 (8) REPORTS TO CONGRESS.— 

20 (A) PRELIMINARY REPORT.—Not later 

21 than 3 years after the date of enactment of this 

22 Act, the Secretary shall submit to the Com23 mittee on Ways and Means of the House of 

24 Representatives and to the Committee on Fi-
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1 nance of the Senate a preliminary report on the 

2 progress made in the demonstration projects. 

3 (B) INTERIM REPORT.—Not later than 30 

4 months after the implementation of the dem5 onstration projects, the Secretary, in consulta6 tion with participants in the projects, shall sub7 mit to the committees described in subpara8 graph (A) an interim report on the demonstra9 tion projects. 

10 (C) FINAL REPORT.—Not later than the 

11 date on which the demonstration projects end, 

12 the Secretary shall submit a final report to the 

13 committees described in subparagraph (A) on 

14 the demonstration projects that includes the re15 sults of the evaluation conducted under para16 graph (7) and recommendations for appropriate 

17 legislative changes. 

18 (9) WAIVER OF MEDICARE REQUIREMENTS.— 

19 The Secretary shall waive compliance with such re20 quirements of the medicare program to the extent 

21 and for the period the Secretary finds necessary to 

22 conduct the demonstration projects. 

23 (10) SPECIAL RULES FOR PAYMENT OF MEDI24 CARE ADVANTAGE ORGANIZATIONS.—The Secretary 

25 shall establish procedures under which the Secretary 
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1 provides for an appropriate adjustment in the 

2 monthly payments made under section 1853 of the 

3 Social Security Act (42 U.S.C. 1395w–23) to any 

4 Medicare Advantage organization offering a Medi5 care Advantage plan to reflect the participation of 

6 each seriously ill medicare beneficiary enrolled in 

7 such plan in a demonstration project. 

8 (c) HOSPICE EDUCATION GRANT PROGRAM.— 

9 (1) IN GENERAL.—The Secretary shall establish 

10 a Hospice Education Grant program under which 

11 the Secretary awards education grants to entities 

12 participating in the demonstration projects for the 

13 purpose of providing information about— 

14 (A) the hospice care under the medicare 

15 program; and 

16 (B) the benefits available to medicare 

17 beneficiaries under the demonstration projects. 

18 (2) USE OF FUNDS.—Grants awarded under 

19 paragraph (1) shall be used— 

20 (A) to provide— 

21 (i) individual or group education to 

22 medicare beneficiaries and the families of 

23 such beneficiaries; and 
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1 (ii) individual or group education of 

2 the medical and mental health community 

3 caring for medicare beneficiaries; and 

4 (B) to test strategies to improve the gen5 eral public knowledge about hospice care under 

6 the medicare program and the benefits available 

7 to medicare beneficiaries under the demonstra8 tion projects. 

9 (d) FUNDING.— 

10 (1) HOSPICE DEMONSTRATION PROJECTS.— 

11 (A) IN GENERAL.—Except as provided in 

12 subparagraph (B), the Secretary shall provide 

13 for the transfer from the Federal Hospital In14 surance Trust Fund under section 1817 of the 

15 Social Security Act (42 U.S.C. 1395i) such 

16 sums as may be necessary to carry out this sec17 tion. 

18 (B) SUPPORTIVE AND COMFORT CARE

19 BENEFIT.—The Secretary shall provide for the 

20 transfer from the Federal Hospital Insurance 

21 Trust Fund under section 1817 of the Social 

22 Security Act (42 U.S.C. 1395i) and the Federal 

23 Supplementary Medical Insurance Trust Fund 

24 established under section 1841 of such Act (42 

25 U.S.C. 1395t), in such proportion as the Sec-
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1 retary determines is appropriate, such sums as 

2 may be necessary to provide for payment of the 

3 costs attributable to the supportive and comfort 

4 care benefit. 

5 (2) HOSPICE EDUCATION GRANTS.—The Sec6 retary shall expend such sums as may be necessary 

7 for the purposes of carrying out the Hospice Edu8 cation Grant program established under subsection 

9 (c)(1) from the Research and Demonstration Budget 

10 of the Centers for Medicare & Medicaid Services. 

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