II 

111TH CONGRESS 

1ST SESSION S. 1251 

To amend title XVIII of the Social Security Act to provide for advanced 

illness care management services for Medicare beneficiaries, and for 

other purposes. 

IN THE SENATE OF THE UNITED STATES 

JUNE 11, 2009 

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

to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act to provide 

for advanced illness care management services for Medicare beneficiaries, 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; TABLE OF CONTENTS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Senior Navigation and Planning Act of 2009’’. 

6 (b) TABLE OF CONTENTS.—The table of contents of 

7 this Act is as follows: 

Sec. 1. Short title; table of contents. 

Sec. 2. Medicare and Medicaid coverage of advanced illness care management 

services. 

Sec. 3. Increasing awareness of the importance of end-of-life planning. 


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Sec. 4. Inclusion of end-of-life planning materials in the Medicare & You handbook. 

Sec. 5. Senior Navigation Advisory Board. 

Sec. 6. Requirement for physicians and nurse practitioners to provide certain 

Medicare beneficiaries with information on advance directives 

and other end-of-life planning tools. 

Sec. 7. Improvement of policies related to the use and portability of advance 

directives. 

Sec. 8. Additional requirements for facilities. 

Sec. 9. Requirement for Medicare providers to honor written orders for medical 

care. 

Sec. 10. Incentives for accreditation and certification in hospice and palliative 

care. 

Sec. 11. Discharge checklist pilot program. 

Sec. 12. Office of Medicare/Medicaid Integration. 

Sec. 13. Web-based materials and grants. 

Sec. 14. HHS study and report on the storage of advance directives. 

Sec. 15. GAO study and report on the provisions of, and amendments made by, 

this Act. 

1 SEC. 2. MEDICARE AND MEDICAID COVERAGE OF AD2 VANCED ILLNESS CARE MANAGEMENT SERV3 ICES. 

4 (a) MEDICARE COVERAGE OF ADVANCED ILLNESS

5 CARE MANAGEMENT SERVICES.— 

6 (1) COVERAGE.—Section 1812(a)(5) of the So7 cial Security Act (42 U.S.C. 1395d(a)(5)) is amend8 ed to read as follows: 

9 ‘‘(5) for individuals who have a life expectancy 

10 of 18 months or less and who have not made an 

11 election under subsection (d)(1) to receive hospice 

12 care under this part, advanced illness care manage13 ment services (as defined in section 1861(hhh)).’’. 

14 (2) DEFINITION.—Section 1861 of the Social 

15 Security Act (42 U.S.C. 1395x) is amended by add16 ing at the end the following new subsection: 


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1 ‘‘Advanced Illness Care Management Services 

2 ‘‘(hhh)(1) The term ‘advanced illness care manage3 ment services’ means the following services furnished to 

4 an individual by a hospice program, as defined in sub5 section (dd)(2): 

6 ‘‘(A) Palliative care consultation services. 

7 ‘‘(B) Care planning services. 

8 ‘‘(C) Counseling of individual and family mem9 bers. 

10 ‘‘(D) Discussions regarding the availability of 

11 supportive services (including information on ad12 vance care planning). 

13 ‘‘(E) Patient-centered care. 

14 ‘‘(F) Family conference services. 

15 ‘‘(G) Respite services. 

16 ‘‘(H) Onsite caregiver training. 

17 ‘‘(I) Such other services as may be appropriate 

18 under a hospice model of care. 

19 ‘‘(2) For purposes of paragraph (1)(F), the term 

20 ‘family conference services’ means a family conference 

21 held by a hospice program (as so defined) for the indi22 vidual and the family members of the individual, including 

23 services for the facilitation and provision of adequate fol24 low-up to such family conference, which includes addi25 tional collaboration and coordination with the hospice phyVerDate Nov 24 2008 01:17 Jun 16, 2009 Jkt 079200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S1251.IS S1251

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1 sician or other hospice personnel to clarify and put into 

2 action the goals of care as outlined by the individual and 

3 the family members of the individual. 

4 ‘‘(3)(A) For purposes of paragraph (1)(G), the term 

5 ‘respite services’ means the provision of additional hours 

6 of care to individuals who are unable to perform 2 or more 

7 activities of daily living. Such services shall be targeted 

8 toward furnishing services to the individual and providing 

9 the caregivers of the individual a needed break outside of 

10 the home of the individual. 

11 ‘‘(B) For purposes of subparagraph (A), the Sec12 retary shall establish, on an annual basis, a minimum and 

13 maximum number of hours (not to exceed 16 hours each 

14 month) for which respite services may be provided to indi15 viduals eligible to receive such services. 

16 ‘‘(C) In subparagraph (A), the term ‘activities of 

17 daily living’ means bathing, transferring, toileting, and 

18 feeding. 

19 ‘‘(4) For purposes of paragraph (1)(H), the term ‘on20 site caregiver training’ means training provided to the 

21 caregivers of an individual, which is focused on training 

22 such caregivers to provide effective personal and technical 

23 care to individuals, with an emphasis on what the care24 giver can expect with the disease process of the individual 

25 or the needs of the individual at the end of life. Such trainVerDate Nov 24 2008 01:17 Jun 16, 2009 Jkt 079200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S1251.IS S1251

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1 ing shall be pragmatic and easily understood by non2 health professionals as well as culturally and educationally 

3 appropriate. 

4 ‘‘(5) In the case of a hospice program that is fur5 nishing advanced illness care management services to an 

6 individual who becomes eligible for hospice care under this 

7 title, the hospice program shall notify the individual of 

8 such eligibility.’’. 

9 (3) PAYMENT BASED ON THE PHYSICIAN FEE

10 SCHEDULE.—Section 1814(i)(4) of the Social Secu11 rity Act (42 U.S.C. 1395f(i)(4)) is amended to read 

12 as follows: 

13 ‘‘(4) The amount paid to a hospice program with re14 spect to the advanced illness care management services (as 

15 defined in section 1861(hhh)) for which payment may be 

16 made under this part shall be— 

17 ‘‘(A) with respect to such services, other than 

18 respite services, furnished by a hospice physician, an 

19 amount equal to the amount that would be paid for 

20 an equivalent physician consultation under the fee 

21 schedule established under section 1848(b); 

22 ‘‘(B) with respect to such services, other than 

23 respite services, furnished by other hospice per24 sonnel, an amount equal to 85 percent of such fee 

25 schedule amount; and 


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1 ‘‘(C) with respect to respite services, payment 

2 shall be at an appropriate rate to be determined by 

3 the Secretary’’. 

4 (4) CONFORMING AMENDMENTS.—Section 

5 1862(a) of the Social Security Act (42 U.S.C. 

6 1395y(a)) is amended— 

7 (A) in paragraph (1)— 

8 (i) by striking ‘‘and’’ at the end of 

9 subparagraph (N); 

10 (ii) by striking the semicolon at the 

11 end of subparagraph (O) and inserting ‘‘, 

12 and’’; and 

13 (iii) by adding at the end the fol14 lowing new subparagraph: 

15 ‘‘(P) in the case of advanced illness care 

16 management services which are respite services 

17 (as defined in section 1861(hhh)(3)), which are 

18 performed more frequently than is provided 

19 under clause (ii) of such section;’’; and 

20 (B) in paragraph (7), by striking ‘‘or (K)’’ 

21 and inserting ‘‘(K), or (P)’’. 

22 (5) EFFECTIVE DATE.—The amendments made 

23 by this subsection shall apply to services furnished 

24 on or after January 1, 2011. 


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1 (b) MEDICAID COVERAGE OF ADVANCED ILLNESS

2 CARE MANAGEMENT SERVICES.— 

3 (1) IN GENERAL.—Section 1905(a) of the So4 cial Security Act (42 U.S.C. 1396d(a)) is amend5 ed— 

6 (A) by redesignating paragraph (28) as 

7 paragraph (29); 

8 (B) in paragraph (27), by striking at the 

9 end ‘‘and’’; and 

10 (C) by inserting after paragraph (27) the 

11 following new paragraph: 

12 ‘‘(28) advanced illness care management serv13 ices (as defined in section 1861(hhh)) for individuals 

14 described in section 1812(a)(5); and’’. 

15 (2) CONFORMING AMENDMENT.—Section 

16 1902(a)(10)(A) of the Social Security Act (42 

17 U.S.C. 1396a(a)(10)(A)) is amended by striking 

18 ‘‘and (21)’’ and inserting ‘‘, (21), and (28)’’. 

19 (3) EFFECTIVE DATE.— 

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

21 subparagraph (B), the amendments made by 

22 paragraphs (1) and (2) take effect on January 

23 1, 2011. 

24 (B) EXTENSION OF EFFECTIVE DATE FOR

25 STATE LAW AMENDMENT.—In the case of a 


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1 State plan under title XIX of the Social Secu2 rity Act (42 U.S.C. 1396 et seq.) which the 

3 Secretary determines requires State legislation 

4 in order for the plan to meet the additional re5 quirements imposed by the amendments made 

6 by paragraph (1), the State plan shall not be 

7 regarded as failing to comply with the require8 ments of such title solely on the basis of its fail9 ure to meet these additional requirements be10 fore the first day of the first calendar quarter 

11 beginning after the close of the first regular 

12 session of the State legislature that begins after 

13 the date of enactment of this Act. For purposes 

14 of the previous sentence, in the case of a State 

15 that has a 2-year legislative session, each year 

16 of the session is considered to be a separate 

17 regular session of the State legislature. 

18 (c) EDUCATION ON ADVANCED ILLNESS CARE MAN19 AGEMENT SERVICES.—The Secretary of Health and 

20 Human Services (in this section referred to as the ‘‘Sec21 retary’’) shall establish a program under which physicians 

22 (as defined in subsection (r) of section 1861 of the Social 

23 Security Act (42 U.S.C. 1395x)) are educated on the cov24 erage of advanced illness care management services (as de25 fined in subsection (hhh) of such section) under the MediVerDate Nov 24 2008 01:17 Jun 16, 2009 Jkt 079200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S1251.IS S1251

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1 care and Medicaid programs under titles XVIII and XIX, 

2 respectively, of the Social Security Act (42 U.S.C. 1395 

3 et seq.; 1396 et seq.), including the importance of early 

4 intervention in providing such care to individuals. 

5 SEC. 3. INCREASING AWARENESS OF THE IMPORTANCE OF 

6 END-OF-LIFE PLANNING. 

7 Title III of the Public Health Service Act (42 U.S.C. 

8 241 et seq.) is amended by adding at the end the following 

9 new part: 

10 ‘‘PART S—PROGRAMS TO INCREASE AWARENESS 

11 OF ADVANCE CARE PLANNING ISSUES 

12 ‘‘SEC. 399GG. ADVANCE CARE PLANNING EDUCATION CAM13 PAIGNS AND INFORMATION PHONE LINE AND 

14 CLEARINGHOUSE. 

15 ‘‘(a) ADVANCE CARE PLANNING EDUCATION CAM16 PAIGN.—The Secretary shall, directly or through grants 

17 awarded under subsection (c), conduct a national public 

18 education campaign— 

19 ‘‘(1) to raise public awareness of the impor20 tance of planning for care near the end of life; 

21 ‘‘(2) to improve the public’s understanding of 

22 the various situations in which individuals may find 

23 themselves if they become unable to express their 

24 health care wishes; 


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1 ‘‘(3) to explain the need for readily available 

2 legal documents that express an individual’s wishes 

3 through— 

4 ‘‘(A) advance directives (including living 

5 wills, comfort care orders, and durable powers 

6 of attorney for health care); and 

7 ‘‘(B) other planning tools, such as a physi8 cian’s orders for life-sustaining treatment 

9 (POLST); and 

10 ‘‘(4) to educate the public about the availability 

11 of hospice care and palliative care. 

12 ‘‘(b) INFORMATION PHONE LINE AND CLEARING13 HOUSE.—The Secretary, directly or through grants 

14 awarded under subsection (c), shall provide for the estab15 lishment of a national, toll-free, information telephone line 

16 and a clearinghouse that the public and health care profes17 sionals may access to find out about State-specific and 

18 other information regarding advance directive and end-of19 life decisions. 

20 ‘‘(c) GRANTS.— 

21 ‘‘(1) IN GENERAL.—The Secretary shall use 

22 funds appropriated under subsection (d) for the pur23 pose of awarding grants to public or nonprofit pri24 vate entities (including States or political subdivi25 sions of a State), or a consortium of any of such enVerDate Nov 24 2008 01:17 Jun 16, 2009 Jkt 079200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S1251.IS S1251

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1 tities, for the purpose of conducting education cam2 paigns under subsection (a). 

3 ‘‘(2) PERIOD.—Any grant awarded under para4 graph (1) shall be for a period of 3 years. 

5 ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There 

6 are authorized to be appropriated— 

7 ‘‘(1) for purposes of carrying out subsection 

8 (b), $5,000,000 for fiscal year 2010 and each subse9 quent year; and 

10 ‘‘(2) for purposes of making grants under sub11 section (c), $10,000,000 for fiscal year 2010, to re12 main available until expended.’’. 

13 SEC. 4. INCLUSION OF END-OF-LIFE PLANNING MATERIALS 

14 IN THE MEDICARE & YOU HANDBOOK. 

15 (a) IN GENERAL.—Section 1804(a) of the Social Se16 curity Act (42 U.S.C. 1395b–2(a)) is amended— 

17 (1) in paragraph (2), by striking ‘‘and’’ at the 

18 end; 

19 (2) in paragraph (3), by striking the period at 

20 the end and inserting ‘‘; and’’; and 

21 (3) by inserting after paragraph (3) the fol22 lowing new paragraph: 

23 ‘‘(4) information on advance directives, other 

24 end-of-life planning tools, and the hospice care ben25 efit under this title.’’. 


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1 (b) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to notices distributed on or after 

3 January 1, 2011. 

4 SEC. 5. SENIOR NAVIGATION ADVISORY BOARD. 

5 (a) ESTABLISHMENT.—The Secretary of Health and 

6 Human Services shall establish the Senior Navigation Ad7 visory Board (in this section referred to as the ‘‘Advisory 

8 Board’’). 

9 (b) MEMBERSHIP.—The Board shall be comprised of 

10 advocates, researchers, government officials, health care 

11 providers, ethicists, caregivers, and other individuals with 

12 expertise in issues related to end-of-life care. 

13 (c) DUTIES.—The Advisory Board shall advise the 

14 Secretary on issues related to end-of-life care and advance 

15 care planning, including how to— 

16 (1) increase patients’ quality of life; 

17 (2) reduce current legal hurdles to the enforce18 ment of advance directives; 

19 (3) encourage provider participation in edu20 cational and training activities surrounding ad21 vanced illnesses and end-of-life care planning; 

22 (4) develop quality and outcome measures that 

23 hospice programs should report for advanced illness 

24 care management services (as defined in section 


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1 1861(hhh) of the Social Security Act, as added by 

2 section 2); 

3 (5) determine what information should be dis4 cussed in discharge planning; and 

5 (6) enhance advance care planning. 

6 (d) APPLICATION OF FACA.—The Federal Advisory 

7 Committee Act (5 U.S.C. App.) shall apply to the Advisory 

8 Board. 

9 (e) PAY AND REIMBURSEMENT.— 

10 (1) NO COMPENSATION FOR MEMBERS OF ADVI11 SORY BOARD.—Except as provided in paragraph (2), 

12 a member of the Advisory Board may not receive 

13 pay, allowances, or benefits by reason of their serv14 ice on the Board. 

15 (2) TRAVEL EXPENSES.—Each member shall 

16 receive travel expenses, including per diem in lieu of 

17 subsistence under subchapter I of chapter 57 of title 

18 5, United States Code. 

19 (f) REPORT.—Not later than 3 years after the estab20 lishment of the Advisory Board, the Advisory Board shall 

21 submit to Congress a final report containing the findings 

22 and conclusions of the Advisory Board, together with rec23 ommendations for such legislation and administrative ac24 tions as the Advisory Board considers appropriate. 


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1 (g) TERMINATION.—The Advisory Board shall termi2 nate 30 days after submitting the report under subsection 

3 (f). 

4 (h) AUTHORIZATION OF APPROPRIATIONS.—There 

5 are authorized to be appropriated such sums as may be 

6 necessary to carry out this section. 

7 SEC. 6. REQUIREMENT FOR PHYSICIANS AND NURSE PRAC8 TITIONERS TO PROVIDE CERTAIN MEDICARE 

9 BENEFICIARIES WITH INFORMATION ON AD10 VANCE DIRECTIVES AND OTHER END-OF-LIFE 

11 PLANNING TOOLS. 

12 Section 1834 of the Social Security Act (42 U.S.C. 

13 1395m) is amended by adding at the end the following 

14 new subsection: 

15 ‘‘(n) REQUIREMENT FOR PHYSICIANS AND NURSE

16 PRACTITIONERS TO PROVIDE CERTAIN INDIVIDUALS

17 WITH INFORMATION ON ADVANCE DIRECTIVES AND

18 OTHER END-OF-LIFE PLANNING TOOLS.— 

19 ‘‘(1) IN GENERAL.—No payment may be made 

20 under this title to a physician (as defined in section 

21 1861(r)) or a nurse practitioner (as defined in sec22 tion 1861(aa)(5)(A)) for items and services fur23 nished on or after January 1, 2014, unless the phy24 sician or nurse practitioner agrees (under a process 

25 established by the Secretary) to provide individuals 


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1 described in paragraph (2) with information on ad2 vance directives and other end-of-life planning tools. 

3 Such information shall be provided in a form and 

4 manner, and at a time, determined appropriate by 

5 the Secretary. 

6 ‘‘(2) INDIVIDUAL DESCRIBED.—An individual 

7 described in this paragraph is an individual entitled 

8 to, or enrolled for, benefits under part A or enrolled 

9 for benefits under this part with— 

10 ‘‘(A) metastatic solid organ cancer; 

11 ‘‘(B) congestive heart failure; 

12 ‘‘(C) end stage renal disease; 

13 ‘‘(D) a progressive neurodegenerative dis14 order; 

15 ‘‘(E) oxygen dependent chronic pulmonary 

16 disease; or 

17 ‘‘(F) any other condition with a similar 

18 level of medical necessity determined appro19 priate by the Secretary.’’. 

20 SEC. 7. IMPROVEMENT OF POLICIES RELATED TO THE USE 

21 AND PORTABILITY OF ADVANCE DIRECTIVES. 

22 (a) MEDICARE.—Section 1866(f) of the Social Secu23 rity Act (42 U.S.C. 1395cc(f)) is amended— 

24 (1) in paragraph (1)— 


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1 (A) in subparagraph (B), by inserting 

2 ‘‘and if presented by the individual (or on be3 half of the individual), to include the content of 

4 such advance directive in a prominent part of 

5 such record’’ before the semicolon at the end; 

6 (B) in subparagraph (D), by striking 

7 ‘‘and’’ after the semicolon at the end; 

8 (C) in subparagraph (E), by striking the 

9 period at the end and inserting ‘‘; and’’; and 

10 (D) by inserting after subparagraph (E) 

11 the following new subparagraph: 

12 ‘‘(F) to provide each individual with the oppor13 tunity to discuss issues relating to the information 

14 provided to that individual pursuant to subpara15 graph (A) with an appropriately trained profes16 sional.’’; 

17 (2) in paragraph (3), by striking ‘‘a written’’ 

18 and inserting ‘‘an’’; and 

19 (3) by adding at the end the following new 

20 paragraph: 

21 ‘‘(5)(A) In addition to the requirements of paragraph 

22 (1), a provider of services, Medicare Advantage organiza23 tion, or prepaid or eligible organization (as the case may 

24 be) shall give effect to an advance directive executed out25 side the State in which such directive is presented, even 


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1 one that does not appear to meet the formalities of execu2 tion, form, or language required by the State in which it 

3 is presented to the same extent as such provider or organi4 zation would give effect to an advance directive that meets 

5 such requirements, except that a provider or organization 

6 may decline to honor such a directive if the provider or 

7 organization can reasonably demonstrate that it is not an 

8 authentic expression of the individual’s wishes concerning 

9 his or her health care. Nothing in this paragraph shall 

10 be construed to authorize the administration of medical 

11 treatment otherwise prohibited by the laws of the State 

12 in which the directive is presented. 

13 ‘‘(B) The provisions of this paragraph shall preempt 

14 any State law to the extent such law is inconsistent with 

15 such provisions. The provisions of this paragraph shall not 

16 preempt any State law that provides for greater port17 ability, more deference to a patient’s wishes, or more lati18 tude in determining a patient’s wishes.’’. 

19 (b) MEDICAID.—Section 1902(w) of the Social Secu20 rity Act (42 U.S.C. 1396a(w)) is amended— 

21 (1) in paragraph (1)— 

22 (A) in subparagraph (B)— 

23 (i) by striking ‘‘in the individual’s 

24 medical record’’ and inserting ‘‘in a promiVerDate Nov 24 2008 01:17 Jun 16, 2009 Jkt 079200 PO 00000 Frm 00017 Fmt 6652 Sfmt 6201 E:\BILLS\S1251.IS S1251

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1 nent part of the individual’s current med2 ical record’’; and 

3 (ii) by inserting ‘‘and if presented by 

4 the individual (or on behalf of the indi5 vidual), to include the content of such ad6 vance directive in a prominent part of such 

7 record’’ before the semicolon at the end; 

8 (B) in subparagraph (D), by striking 

9 ‘‘and’’ after the semicolon at the end; 

10 (C) in subparagraph (E), by striking the 

11 period at the end and inserting ‘‘; and’’; and 

12 (D) by inserting after subparagraph (E) 

13 the following new subparagraph: 

14 ‘‘(F) to provide each individual with the oppor15 tunity to discuss issues relating to the information 

16 provided to that individual pursuant to subpara17 graph (A) with an appropriately trained profes18 sional.’’; 

19 (2) in paragraph (4), by striking ‘‘a written’’ 

20 and inserting ‘‘an’’; and 

21 (3) by adding at the end the following para22 graph: 

23 ‘‘(6)(A) In addition to the requirements of paragraph 

24 (1), a provider or organization (as the case may be) shall 

25 give effect to an advance directive executed outside the 


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1 State in which such directive is presented, even one that 

2 does not appear to meet the formalities of execution, form, 

3 or language required by the State in which it is presented 

4 to the same extent as such provider or organization would 

5 give effect to an advance directive that meets such require6 ments, except that a provider or organization may decline 

7 to honor such a directive if the provider or organization 

8 can reasonably demonstrate that it is not an authentic ex9 pression of the individual’s wishes concerning his or her 

10 health care. Nothing in this paragraph shall be construed 

11 to authorize the administration of medical treatment oth12 erwise prohibited by the laws of the State in which the 

13 directive is presented. 

14 ‘‘(B) The provisions of this paragraph shall preempt 

15 any State law to the extent such law is inconsistent with 

16 such provisions. The provisions of this paragraph shall not 

17 preempt any State law that provides for greater port18 ability, more deference to a patient’s wishes, or more lati19 tude in determining a patient’s wishes.’’. 

20 (c) EFFECTIVE DATES.— 

21 (1) IN GENERAL.—Subject to paragraph (2), 

22 the amendments made by subsections (a) and (b) 

23 shall apply to provider agreements and contracts en24 tered into, renewed, or extended under title XVIII of 

25 the Social Security Act (42 U.S.C. 1395 et seq.), 


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1 and to State plans under title XIX of such Act (42 

2 U.S.C. 1396 et seq.), on or after such date as the 

3 Secretary of Health and Human Services specifies, 

4 but in no case may such date be later than 1 year 

5 after the date of enactment of this Act. 

6 (2) EXTENSION OF EFFECTIVE DATE FOR

7 STATE LAW AMENDMENT.—In the case of a State 

8 plan under title XIX of the Social Security Act (42 

9 U.S.C. 1396 et seq.) which the Secretary of Health 

10 and Human Services determines requires State legis11 lation in order for the plan to meet the additional 

12 requirements imposed by the amendments made by 

13 subsection (b), the State plan shall not be regarded 

14 as failing to comply with the requirements of such 

15 title solely on the basis of its failure to meet these 

16 additional requirements before the first day of the 

17 first calendar quarter beginning after the close of 

18 the first regular session of the State legislature that 

19 begins after the date of enactment of this Act. For 

20 purposes of the previous sentence, in the case of a 

21 State that has a 2-year legislative session, each year 

22 of the session is considered to be a separate regular 

23 session of the State legislature. 

24 SEC. 8. ADDITIONAL REQUIREMENTS FOR FACILITIES. 

25 (a) REQUIREMENTS.— 


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1 (1) IN GENERAL.—Section 1866(a)(1) of the 

2 Social Security Act (42 U.S.C. 1395cc(a)(1)) is 

3 amended— 

4 (A) in subsection (a)(1)— 

5 (i) in subparagraph (U), by striking 

6 ‘‘and’’ at the end; 

7 (ii) in subparagraph (V), by striking 

8 the period at the end and inserting a 

9 comma; and 

10 (iii) by inserting after subparagraph 

11 (V) the following new subparagraphs: 

12 ‘‘(W) in the case of hospitals, skilled nursing 

13 facilities, home health agencies, and hospice pro14 grams, to provide individuals receiving care by or 

15 through the provider (and their caregivers and fami16 lies, with the patient’s consent, or their surrogate 

17 decision-makers) with the opportunity to discuss the 

18 general course of treatment expected, the likely im19 pact on length of life and function, and the proce20 dures they should use to secure help if an unex21 pected situation arises, and 

22 ‘‘(X) in the case of hospitals, skilled nursing fa23 cilities, and hospice programs, to— 

24 ‘‘(i) provide for an assessment of each indi25 vidual (at the time of discharge from the proVerDate Nov 24 2008 01:17 Jun 16, 2009 Jkt 079200 PO 00000 Frm 00021 Fmt 6652 Sfmt 6201 E:\BILLS\S1251.IS S1251

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1 vider) using an assessment instrument that is 

2 at least as informative as the continuity assess3 ment record and evaluation (CARE) instrument 

4 developed by the Centers for Medicare & Med5 icaid Services; and 

6 ‘‘(ii) include the results of such assessment 

7 in the individual’s medical record.’’. 

8 (2) EFFECTIVE DATE.—The amendments made 

9 by this subsection shall apply to agreements entered 

10 into or renewed on or after January 1, 2012. 

11 (b) HHS STUDY AND REPORT ON APPROPRIATE AS12 SESSMENTS AT DISCHARGE.— 

13 (1) STUDY.—The Secretary of Health and 

14 Human Services shall conduct a study on the extent 

15 to which the assessment of individual by hospitals, 

16 skilled nursing facilities, and hospice programs 

17 under section 1886(a)(1)(X) of the Social Security 

18 Act, as added by subsection (a), accurately reflects 

19 the actual diagnosis and care plan of the individual 

20 involved at the time of discharge. 

21 (2) REPORT.—Not later than January 1, 2014, 

22 the Secretary of Health and Human Services shall 

23 submit to Congress a report on the study conducted 

24 under paragraph (1) together with recommendations 


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1 for such legislation and administrative action as the 

2 Secretary determines to be appropriate. 

3 SEC. 9. REQUIREMENT FOR MEDICARE PROVIDERS TO 

4 HONOR WRITTEN ORDERS FOR MEDICAL 

5 CARE. 

6 Section 1834 of the Social Security Act (42 U.S.C. 

7 1395m), as amended by section 6, is amended by adding 

8 at the end the following new subsection: 

9 ‘‘(o) REQUIREMENT TO HONOR WRITTEN ORDERS

10 FOR MEDICAL CARE.—No payment may be made under 

11 this title to a provider of services or a supplier for items 

12 and services furnished on or after January 1, 2013, unless 

13 the provider or supplier agrees (under a process estab14 lished by the Secretary) to, in the case of an individual 

15 with a written order for medical care (such as a physi16 cian’s orders for life-sustaining treatment (POLST)), fol17 low such order when furnishing items and services to the 

18 individual.’’. 

19 SEC. 10. INCENTIVES FOR ACCREDITATION AND CERTIFI20 CATION IN HOSPICE AND PALLIATIVE CARE. 

21 (a) HOSPITALS.—Section 1886 of the Social Security 

22 Act (42 U.S.C. 1395ww) is amended by adding at the end 

23 the following new subsection: 

24 ‘‘(o) INCENTIVES FOR ACCREDITATION IN PALLIA25 TIVE CARE.— 


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1 ‘‘(1) INCENTIVE PAYMENT.— 

2 ‘‘(A) IN GENERAL.—Subject to subpara3 graph (3), with respect to inpatient hospital 

4 services and inpatient critical access hospital 

5 services furnished by an eligible hospital during 

6 a payment year, if the eligible hospital has in 

7 place an accredited palliative care program (as 

8 determined by the Secretary) with respect to 

9 such year and meets utilization criteria for such 

10 program (as established by the Secretary) with 

11 respect to such year, in addition to the amount 

12 otherwise paid under this section or section 

13 1814, there shall also be paid to the eligible 

14 hospital, from the Federal Hospital Insurance 

15 Trust Fund established under section 1817, an 

16 amount equal to the applicable percent of the 

17 amount that would otherwise be paid under this 

18 section or section 1814 for such services for the 

19 hospital for such year. 

20 ‘‘(B) APPLICABLE PERCENT DEFINED.— 

21 The term ‘applicable percent’ means— 

22 ‘‘(i) for fiscal years 2011 through 

23 2016, 2 percent; and 

24 ‘‘(ii) for fiscal years 2017 through 

25 2020, 1 percent. 


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1 ‘‘(C) FORM OF PAYMENT.—The payment 

2 under this paragraph for a payment year may 

3 be in the form of a single consolidated payment 

4 or in the form of such periodic installments as 

5 the Secretary may specify. 

6 ‘‘(2) INCENTIVE PAYMENT ADJUSTMENT.—Sub7 ject to paragraph (3), with respect to inpatient hos8 pital services and inpatient critical access hospital 

9 services furnished by an eligible hospital during a 

10 fiscal year after fiscal year 2020, if the eligible hos11 pital does not have in place an accredited palliative 

12 care program (as determined by the Secretary) with 

13 respect to such fiscal year, the amount otherwise 

14 paid under this section or section 1814 for such 

15 services for the hospital for the year shall be reduced 

16 by 1 percent. 

17 ‘‘(3) EXCEPTION.—In the case of an eligible 

18 hospital with fewer than 50 beds, such hospital shall 

19 be deemed to meet the requirement in paragraphs 

20 (1)(A) and (2) if, in lieu of having in place an ac21 credited palliative care program, the hospital pro22 vides patients and family members with access to a 

23 local or regional accredited palliative care team or 

24 program. 

25 ‘‘(4) DEFINITIONS.—In this subsection: 


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1 ‘‘(A) ELIGIBLE HOSPITAL.—The term ‘eli2 gible hospital’ means— 

3 ‘‘(i) a hospital (as defined in section 

4 1861(e)); and 

5 ‘‘(ii) a critical access hospital (as de6 fined in section 1861(mm)(1)). 

7 ‘‘(B) PAYMENT YEAR.—The term ‘payment 

8 year’ means fiscal years 2011 through 2020. 

9 ‘‘(5) LIMITATIONS ON REVIEW.—There shall be 

10 no administrative or judicial review under section 

11 1869, section 1878, or otherwise, of— 

12 ‘‘(A) the methodology and standards for 

13 determining payment amounts under paragraph 

14 (1) and payment adjustments under paragraph 

15 (2); 

16 ‘‘(B) the methodology and standards for 

17 determining whether the eligible hospital has in 

18 place an accredited palliative care program; and 

19 ‘‘(C) the application of the exception under 

20 paragraph (3).’’. 

21 (b) SKILLED NURSING FACILITIES.—Section 1888 of 

22 the Social Security Act (42 U.S.C. 1395yy) is amended 

23 by adding at the end the following new subsection: 

24 ‘‘(f) INCENTIVES FOR ACCREDITATION IN PALLIA25 TIVE CARE.— 


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1 ‘‘(1) INCENTIVE PAYMENT.— 

2 ‘‘(A) IN GENERAL.—Subject to subpara3 graph (3), with respect to covered skilled nurs4 ing facility services (as defined in subsection 

5 (e)(2)(A)) furnished by a skilled nursing facility 

6 during a payment year, if the facility has in 

7 place an accredited palliative care program (as 

8 determined by the Secretary) with respect to 

9 such year and meets utilization criteria for such 

10 program (as established by the Secretary) with 

11 respect to such year, in addition to the amount 

12 otherwise paid under this subsection (e), there 

13 shall also be paid to the facility, from the Fed14 eral Hospital Insurance Trust Fund established 

15 under section 1817, an amount equal to the ap16 plicable percent of the amount that would oth17 erwise be paid under subsection (e) for such 

18 services for the facility for such year. 

19 ‘‘(B) DEFINITIONS.—In this subsection: 

20 ‘‘(i) APPLICABLE PERCENT.—The 

21 term ‘applicable percent’ means— 

22 ‘‘(I) for fiscal years 2011 

23 through 2016, 2 percent; and 

24 ‘‘(II) for fiscal years 2017 

25 through 2020, 1 percent. 


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1 ‘‘(ii) PAYMENT YEAR.—The term 

2 ‘payment year’ means fiscal years 2011 

3 through 2020. 

4 ‘‘(C) FORM OF PAYMENT.—The payment 

5 under this paragraph for a payment year may 

6 be in the form of a single consolidated payment 

7 or in the form of such periodic installments as 

8 the Secretary may specify. 

9 ‘‘(2) INCENTIVE PAYMENT ADJUSTMENT.—Sub10 ject to paragraph (3), with respect to covered skilled 

11 nursing facility services (as defined in subsection 

12 (e)(2)(A)) furnished by a skilled nursing facility dur13 ing a fiscal year after fiscal year 2020, if the facility 

14 does not have in place an accredited palliative care 

15 program (as determined by the Secretary) with re16 spect to such fiscal year, the amount otherwise paid 

17 under subsection (e) for such services for the facility 

18 for the year shall be reduced by 1 percent. 

19 ‘‘(3) EXCEPTION.—In the case of a skilled 

20 nursing facility with fewer than 60 beds, such facil21 ity shall be deemed to meet the requirement in para22 graphs (1)(A) and (2) if, in lieu of having in place 

23 an accredited palliative care program, the facility 

24 provides patients and family members with access to 


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1 a local or regional accredited palliative care team or 

2 program. 

3 ‘‘(4) LIMITATIONS ON REVIEW.—There shall be 

4 no administrative or judicial review under section 

5 1869, section 1878, or otherwise, of— 

6 ‘‘(A) the methodology and standards for 

7 determining payment amounts under paragraph 

8 (1) and payment adjustments under paragraph 

9 (2); 

10 ‘‘(B) the methodology and standards for 

11 determining whether the skilled nursing facility 

12 has in place an accredited palliative care pro13 gram; and 

14 ‘‘(C) the application of the exception under 

15 paragraph (3).’’. 

16 (c) PHYSICIANS.—Section 1848 of the Social Security 

17 Act (42 U.S.C. 1395w–4) is amended by adding at the 

18 end the following new subsection: 

19 ‘‘(p) INCENTIVES FOR CERTIFICATION IN HOSPICE

20 AND PALLIATIVE CARE.— 

21 ‘‘(1) INCENTIVE PAYMENT.— 

22 ‘‘(A) IN GENERAL.—With respect to physi23 cians’ services furnished by a physician during 

24 a payment year, if the physician is certified in 

25 hospice and palliative care (as determined by 


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1 the Secretary) with respect to such year, in ad2 dition to the amount otherwise paid under this 

3 part, there shall also be paid to the physician, 

4 from the Federal Supplementary Medical Insur5 ance Trust Fund established under section 

6 1841, an amount equal to the applicable per7 cent of the Secretary’s estimate (based on 

8 claims submitted not later than 2 months after 

9 the end of the payment year) of the allowed 

10 charges under this part for all covered profes11 sional services (as defined in subsection (k)(3)) 

12 furnished by the physician during such year. 

13 ‘‘(B) DEFINITIONS.—In this subsection: 

14 ‘‘(i) APPLICABLE PERCENT.—The 

15 term ‘applicable percent’ means— 

16 ‘‘(I) for 2011 through 2016, 2 

17 percent; and 

18 ‘‘(II) for 2017 through 2020, 1 

19 percent. 

20 ‘‘(ii) PAYMENT YEAR.—The term 

21 ‘payment year’ means 2011 through 2020. 

22 ‘‘(C) FORM OF PAYMENT.—The payment 

23 under this subsection for a payment year may 

24 be in the form of a single consolidated payment 


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1 or in the form of such periodic installments as 

2 the Secretary may specify. 

3 ‘‘(2) LIMITATIONS ON REVIEW.—There shall be 

4 no administrative or judicial review under section 

5 1869, section 1878, or otherwise, of— 

6 ‘‘(A) the methodology and standards for 

7 determining payment amounts under paragraph 

8 (1); and 

9 ‘‘(B) the methodology and standards for 

10 determining whether the physician is certified 

11 in hospice and palliative care.’’. 

12 SEC. 11. DISCHARGE CHECKLIST PILOT PROGRAM. 

13 (a) ESTABLISHMENT.—Not later than July 1, 2010, 

14 the Secretary of Health and Human Services (in this sec15 tion referred to as the ‘‘Secretary’’) shall conduct a pilot 

16 program under title XVIII of the Social Security Act to 

17 test the use of the Centers for Medicare and Medicaid 

18 Services’ discharge checklist included in the publication 

19 entitled ‘‘Planning for Your Discharge: A checklist for pa20 tients and caregivers preparing to leave a hospital, nursing 

21 home, or other health care setting’’. 

22 (b) WAIVER AUTHORITY.—The Secretary may waive 

23 compliance of such requirements of titles XI and XVIII 

24 of the Social Security Act as the Secretary determines nec25 essary to conduct the pilot program under this section. 


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1 (c) REPORT.—Not later than 6 months after the com2 pletion of the pilot program under this section, the Sec3 retary shall submit to Congress a final report on the pilot 

4 program, together with recommendations for such legisla5 tion and administrative action as the Secretary determines 

6 appropriate. 

7 (d) FUNDING.—There are authorized to be appro8 priated such sums as may be necessary for purposes of 

9 conducting the pilot program under this section. 

10 SEC. 12. OFFICE OF MEDICARE/MEDICAID INTEGRATION. 

11 (a) ESTABLISHMENT.—The Secretary shall establish 

12 or designate an Office on Medicare/Medicaid Integration 

13 (in this subsection referred to as the ‘‘Office’’) for the pur14 pose of aligning Medicare and Medicaid program policies 

15 and procedures and developing tools to support State inte16 gration efforts in order to— 

17 (1) simplify dual eligible access to Medicare and 

18 Medicaid program benefits and services; 

19 (2) improve care continuity and ensure safe and 

20 effective care transitions; 

21 (3) eliminate cost shifting between the Medicare 

22 and Medicaid programs and among related care pro23 viders; 

24 (4) eliminate regulatory conflicts between Medi25 care and Medicaid program rules; and 


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1 (5) improve total cost and quality performance. 

2 (b) RESPONSIBILITIES.—The responsibilities of the 

3 Office are to develop policies and procedures to— 

4 (1) identify incentives for States to advance the 

5 integration of the Medicare and Medicaid programs 

6 to improve total cost and quality performance, in7 cluding shared cost savings among consumers, plans, 

8 and Federal and State governments with respect to 

9 State initiatives for advancing Medicare and Med10 icaid program integration; 

11 (2) provide support for coordination of Federal 

12 and State contracting and oversight for dual inte13 gration programs supportive of the goals described 

14 in subsection (a); 

15 (3) serve as a liaison between Centers for Medi16 care & Medicaid Services central and regional offices 

17 to ensure consistent application of Centers for Medi18 care & Medicaid Services rules, policies, and auditing 

19 practices as such rules, policies, and auditing prac20 tices pertain to dual eligibles; 

21 (4) monitor total combined Medicare and Med22 icaid program costs in serving dual eligibles and 

23 make recommendations for optimizing total quality 

24 and cost performance across both programs; and 


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1 (5) identify legislative and administrative 

2 changes that are needed to facilitate the integration 

3 of benefits and oversight functions of the Medicare 

4 and Medicaid programs with respect to dual eligi5 bles. 

6 (c) DUAL ELIGIBLE DEFINED.—In this section, the 

7 term ‘‘dual eligible’’ means an individual who is— 

8 (1) entitled to, or enrolled for, benefits under 

9 part A of title XVIII of the Social Security Act or 

10 enrolled for benefits under part B of such title; and 

11 (2) entitled to medical assistance under a State 

12 plan under title XIX of such Act. 

13 (d) STUDY.—Not later than January 1, 2011, the 

14 Secretary of Health and Human Services, in consultation 

15 with private health information technology stakeholders 

16 and in coordination with other Federal health information 

17 technology efforts, shall conduct a study to determine the 

18 data that the Office should collect and analyze in order 

19 to improve health care outcomes, create efficiencies in care 

20 delivery, and impact Federal health care spending. 

21 (e) FUNDING.—There are authorized to be appro22 priated such sums as may be necessary to carry out the 

23 provisions of this section. 


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1 SEC. 13. WEB-BASED MATERIALS AND GRANTS. 

2 (a) WEB-BASED MATERIALS.—The Secretary of 

3 Health and Human Services (in this section referred to 

4 as the ‘‘Secretary’’) shall establish and maintain a website 

5 that provides information, online training, and instruc6 tional materials for entities, including faith-based organi7 zations, on end-of-life issues, which shall include content 

8 addressing— 

9 (1) advance care planning, including common 

10 issues and questions regarding advance directives 

11 and their uses; 

12 (2) hospice benefits under Medicare, Medicaid, 

13 and the State Children’s Health Insurance Program 

14 established under the Social Security Act, including 

15 information on how hospice care is administered and 

16 provided to terminally ill individuals; 

17 (3) palliative care, including information on 

18 services that palliative care units provide for termi19 nally ill patients; and 

20 (4) any additional information related to end21 of-life care and associated issues, as determined by 

22 the Secretary. 

23 (b) GRANTS.— 

24 (1) HOSPICE CARE GRANT PROGRAM.— 

25 (A) GRANTS AUTHORIZED.—The Secretary 

26 is authorized to award grants to entities, inVerDate Nov 24 2008 01:17 Jun 16, 2009 Jkt 079200 PO 00000 Frm 00035 Fmt 6652 Sfmt 6201 E:\BILLS\S1251.IS S1251

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1 cluding faith-based organizations, to develop 

2 and provide services for terminally ill individ3 uals who are receiving hospice care in their own 

4 homes. 

5 (B) REQUIREMENTS.— 

6 (i) DURATION.—The grant program 

7 shall be conducted for a 5-year period, be8 ginning not later than January 1, 2011. 

9 (ii) AMOUNT OF GRANTS.—An entity 

10 may be awarded a grant under this para11 graph for a fiscal year that is not less than 

12 $5,000 and not more than $250,000. 

13 (iii) NUMBER OF GRANTS.—The Sec14 retary shall award grants under this para15 graph to not more than 100 entities. 

16 (C) ADDITIONAL MEDICAID FUNDS.—A 

17 State may elect to provide additional funds to 

18 recipients of a grant under this section, with 

19 such funds to be considered as amounts ex20 pended for the proper and efficient administra21 tion of the State plan under title XIX of the 

22 Social Security Act for purposes of the State 

23 receiving payments under section 1903(a)(7) of 

24 that Act. 


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1 (D) USE OF FUNDS.—Grants awarded 

2 pursuant to this paragraph shall be used by en3 tities to develop and provide end-of-life support 

4 services for terminally ill individuals who are re5 ceiving care in their own homes, including— 

6 (i) support for caregivers; 

7 (ii) if the entity is a hospice program 

8 under the Medicare program, any addi9 tional hospice care determined appropriate 

10 by the Secretary; and 

11 (iii) any additional end-of-life informa12 tion or materials relating to support serv13 ices determined appropriate by the Sec14 retary. 

15 (E) APPLICATION.—Each entity desiring a 

16 grant under this paragraph shall submit an ap17 plication to the Secretary at such time, in such 

18 manner, and accompanied by such information 

19 as the Secretary may reasonably require. 

20 (F) AUTHORIZATION OF APPROPRIA21 TIONS.—For the purpose of carrying out the 

22 grant program established under this para23 graph, there is authorized to be appropriated 

24 $15,000,000 for the period of fiscal years 2011 

25 through 2015. 


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1 (2) END-OF-LIFE EDUCATIONAL GRANT PRO2 GRAM.— 

3 (A) GRANTS AUTHORIZED.—The Secretary 

4 is authorized to award grants to entities, in5 cluding faith-based organizations and religious 

6 educational institutions, to develop and provide 

7 appropriate training and educational programs 

8 addressing end-of-life care issues. 

9 (B) REQUIREMENTS.— 

10 (i) DURATION.—The grant program 

11 shall be conducted for a 5-year period, be12 ginning not later than January 1, 2011. 

13 (ii) AMOUNT OF GRANTS.—An entity 

14 may be awarded a grant under this para15 graph for a fiscal year that is not less than 

16 $5,000, and not more than $50,000. 

17 (iii) NUMBER OF GRANTS.—The Sec18 retary shall award grants under this para19 graph to not more than 100 entities. 

20 (C) USE OF FUNDS.—Grants awarded pur21 suant to this paragraph shall be used by enti22 ties to develop appropriate training and edu23 cation programs addressing end-of-life care 

24 issues and include such programs as part of 


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1 their educational curriculum, continuing edu2 cation programs, or vocational training. 

3 (D) APPLICATION.—Each entity desiring a 

4 grant under this paragraph shall submit an ap5 plication to the Secretary at such time, in such 

6 manner, and accompanied by such information 

7 as the Secretary may reasonably require. 

8 (E) AUTHORIZATION OF APPROPRIA9 TIONS.—For the purpose of carrying out the 

10 grant program established under this para11 graph, there is authorized to be appropriated 

12 $10,000,000 for the period of fiscal years 2011 

13 through 2015. 

14 SEC. 14. HHS STUDY AND REPORT ON THE STORAGE OF AD15 VANCE DIRECTIVES. 

16 (a) STUDY.—The Secretary of Health and Human 

17 Services shall conduct a study on the best methods of stor18 ing completed advance directives. Such study shall include 

19 an analysis of the feasibility of establishing a national reg20 istry for completed advance directives, taking into consid21 eration the constraints created by the privacy provisions 

22 enacted as a result of the Health Insurance Portability 

23 and Accountability Act of 1996 (Public Law 104–191). 

24 (b) REPORT.—Not later than January 1, 2012, the 

25 Secretary of Health and Human Services shall submit to 


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1 Congress a report on the study conducted under sub2 section (a) together with recommendations for such legis3 lation and administrative action as the Secretary deter4 mines to be appropriate. 

5 SEC. 15. GAO STUDY AND REPORT ON THE PROVISIONS OF, 

6 AND AMENDMENTS MADE BY, THIS ACT. 

7 (a) STUDY.—The Comptroller General of the United 

8 States (in this section referred to as the ‘‘Comptroller 

9 General’’) shall conduct a study on the provisions of, and 

10 amendments made by, this Act, including the quality and 

11 costs (such as patient and family experience, patient un12 derstanding of treatment choices, and any decrease in 

13 avoidable hospital admissions) associated with such provi14 sions and such amendments. 

15 (b) REPORT.—Not later than January 1, 2012, the 

16 Comptroller General shall submit to Congress a report 

17 containing the results of the study conducted under sub18 section (a), together with recommendations for such legis19 lation and administrative action as the Comptroller Gen20 eral determines appropriate. 

Æ 


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