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[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 1150 Introduced in Senate (IS)]

111th CONGRESS
  1st Session
                                S. 1150

                      To improve end-of-life care.

_______________________________________________________________________

                   IN THE SENATE OF THE UNITED STATES

                              May 21, 2009

Mr. Reid (for Mr. Rockefeller (for himself, Ms. Collins, Mr. Kohl, Mr. 
 Wyden, and Mr. Carper)) introduced the following bill; which was read 
             twice and referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL

 
                      To improve end-of-life care.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Advance Planning 
and Compassionate Care Act of 2009''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Definitions.
                     TITLE I--ADVANCE CARE PLANNING

              Subtitle A--Consumer and Provider Education

                       Part I--Consumer Education

                    subpart a--national initiatives

Sec. 101. Advance care planning telephone hotline.
Sec. 102. Advance care planning information clearinghouses.
Sec. 103. Advance care planning toolkit.
Sec. 104. National public education campaign.
Sec. 105. Update of Medicare and Social Security handbooks.
Sec. 106. Authorization of appropriations.
                 subpart b--state and local initiatives

Sec. 111. Financial assistance for advance care planning.
Sec. 112. Grants for programs for orders regarding life sustaining 
                            treatment.
                      Part II--Provider Education

Sec. 121. Public provider advance care planning website.
Sec. 122. Continuing education for physicians and nurses.
   Subtitle B--Portability of Advance Directives; Health Information 
                               Technology

Sec. 131. Portability of advance directives.
Sec. 132. State advance directive registries; driver's license advance 
                            directive notation.
Sec. 133. GAO study and report on establishment of national advance 
                            directive registry.
      Subtitle C--National Uniform Policy on Advance Care Planning

Sec. 141. Study and report by the Secretary regarding the establishment 
                            and implementation of a national uniform 
                            policy on advance directives.
                      TITLE II--COMPASSIONATE CARE

                   Subtitle A--Workforce Development

                     Part I--Education and Training

Sec. 201. National Geriatric and Palliative Care Services Corps.
Sec. 202. Exemption of palliative medicine fellowship training from 
                            Medicare graduate medical education caps.
Sec. 203. Medical school curricula.
        Subtitle B--Coverage Under Medicare, Medicaid, and CHIP

               Part I--Coverage of Advance Care Planning

Sec. 211. Medicare, Medicaid, and CHIP coverage.
                            Part II--Hospice

Sec. 221. Adoption of MedPAC hospice payment methodology 
                            recommendations.
Sec. 222. Removing hospice inpatient days in setting per diem rates for 
                            critical access hospitals.
Sec. 223. Hospice payments for dual eligible individuals residing in 
                            long-term care facilities.
Sec. 224. Delineation of respective care responsibilities of hospice 
                            programs and long-term care facilities.
Sec. 225. Adoption of MedPAC hospice program eligibility certification 
                            and recertification recommendations.
Sec. 226. Concurrent care for children.
Sec. 227. Making hospice a required benefit under Medicaid and CHIP.
Sec. 228. Medicare Hospice payment model demonstration projects.
Sec. 229. MedPAC studies and reports.
Sec. 230. HHS Evaluations.
                    Subtitle C--Quality Improvement

Sec. 241. Patient satisfaction surveys.
Sec. 242. Development of core end-of-life care quality measures across 
                            each relevant provider setting.
Sec. 243. Accreditation of hospital-based palliative care programs.
Sec. 244. Survey and data requirements for all Medicare participating 
                            hospice programs.
       Subtitle D--Additional Reports, Research, and Evaluations

Sec. 251. National Center On Palliative and End-of-Life Care.
Sec. 252. National Mortality Followback Survey.
Sec. 253. Demonstration projects for use of telemedicine services in 
                            advance care planning.
Sec. 254. Inspector General investigation of fraud and abuse.
Sec. 255. GAO study and report on provider adherence to advance 
                            directives.

SEC. 2. DEFINITIONS.

    In this Act:
            (1) Advance care planning.--The term ``advance care 
        planning'' means the process of--
                    (A) determining an individual's priorities, values 
                and goals for care in the future when the individual is 
                no longer able to express his or her wishes;
                    (B) engaging family members, health care proxies, 
                and health care providers in an ongoing dialogue 
                about--
                            (i) the individual's wishes for care;
                            (ii) what the future may hold for people 
                        with serious illnesses or injuries;
                            (iii) how individuals, their health care 
                        proxies, and family members want their beliefs 
                        and preferences to guide care decisions; and
                            (iv) the steps that individuals and family 
                        members can take regarding, and the resources 
                        available to help with, finances, family 
                        matters, spiritual questions, and other issues 
                        that impact seriously ill or dying patients and 
                        their families; and
                    (C) executing and updating advance directives and 
                appointing a health care proxy.
            (2) Advance directive.--The term ``advance directive'' 
        means a living will, medical directive, health care power of 
        attorney, durable power of attorney, or other written statement 
        by a competent individual that is recognized under State law 
        and indicates the individual's wishes regarding medical 
        treatment in the event of future incompetence. Such term 
        includes an advance health care directive and a health care 
        directive recognized under State law.
            (3) CHIP.--The term ``CHIP'' means the program established 
        under title XXI of the Social Security Act (42 U.S.C. 1397aa et 
        seq.).
            (4) End-of-life-care.--The term ``end-of-life care'' means 
        all aspects of care of a patient with a potentially fatal 
        condition, and includes care that is focused on specific 
        preparations for an impending death.
            (5) Health care power of attorney.--The term ``health care 
        power of attorney'' means a legal document that identifies a 
        health care proxy or decisionmaker for a patient who has the 
        authority to act on the patient's behalf when the patient is 
        unable to communicate his or her wishes for medical care on 
        matters that the patient specifies when he or she is competent. 
        Such term includes a durable power of attorney that relates to 
        medical care.
            (6) Living will.--The term ``living will'' means a legal 
        document--
                    (A) used to specify the type of medical care 
                (including any type of medical treatment, including 
                life-sustaining procedures if that person becomes 
                permanently unconscious or is otherwise dying) that an 
                individual wants provided or withheld in the event the 
                individual cannot speak for himself or herself and 
                cannot express his or her wishes; and
                    (B) that requires a physician to honor the 
                provisions of upon receipt or to transfer the care of 
                the individual covered by the document to another 
                physician that will honor such provisions.
            (7) Medicaid.--The term ``Medicaid'' means the program 
        established under title XIX of the Social Security Act (42 
        U.S.C. 1396 et seq.).
            (8) Medicare.--The term ``Medicare'' means the program 
        established under title XVIII of the Social Security Act (42 
        U.S.C. 1395 et seq.).
            (9) Orders for life-sustaining treatment.--The term 
        ``orders for life-sustaining treatment'' means a process for 
        focusing a patients' values, goals, and preferences on current 
        medical circumstances and to translate such into visible and 
        portable medical orders applicable across care settings, 
        including home, long-term care, emergency medical services, and 
        hospitals.
            (10) Palliative care.--The term ``palliative care'' means 
        interdisciplinary care for individuals with a life-threatening 
        illness or injury relating to pain and symptom management and 
        psychological, social, and spiritual needs and that seeks to 
        improve the quality of life for the individual and the 
        individual's family.
            (11) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.

                     TITLE I--ADVANCE CARE PLANNING

              Subtitle A--Consumer and Provider Education

                       PART I--CONSUMER EDUCATION

                    Subpart A--National Initiatives

SEC. 101. ADVANCE CARE PLANNING TELEPHONE HOTLINE.

    (a) In General.--Not later than January 1, 2011, the Secretary, 
acting through the Director of the Centers for Disease Control and 
Prevention, shall establish and operate directly, or by grant, 
contract, or interagency agreement, a 24-hour toll-free telephone 
hotline to provide consumer information regarding advance care 
planning, including--
            (1) an explanation of advanced care planning and its 
        importance;
            (2) issues to be considered when developing an individual's 
        advance care plan;
            (3) how to establish an advance directive;
            (4) procedures to help ensure that an individual's 
        directives for end-of-life care are followed;
            (5) Federal and State-specific resources for assistance 
        with advance care planning; and
            (6) hospice and palliative care (including their respective 
        purposes and services).
    (b) Establishment.--In carrying out the requirements under 
subsection (a), the Director of the Centers for Disease Control and 
Prevention may designate an existing 24-hour toll-free telephone 
hotline or, if no such service is available or appropriate, establish a 
new 24-hour toll-free telephone hotline.

SEC. 102. ADVANCE CARE PLANNING INFORMATION CLEARINGHOUSES.

    (a) Expansion of National Clearinghouse for Long-Term Care 
Information.--
            (1) Development.--Not later than January 1, 2010, the 
        Secretary shall develop an online clearinghouse to provide 
        comprehensive information regarding advance care planning.
            (2) Maintenance.--The advance care planning clearinghouse, 
        which shall be clearly identifiable and available on the 
        homepage of the Department of Health and Human Service's 
        National Clearinghouse for Long-Term Care Information website, 
        shall be maintained and publicized by the Secretary on an 
        ongoing basis.
            (3) Content.--The advance care planning clearinghouse shall 
        include--
                    (A) any relevant content contained in the national 
                public education campaign required under section 104;
                    (B) content addressing--
                            (i) an explanation of advanced care 
                        planning and its importance;
                            (ii) issues to be considered when 
                        developing an individual's advance care plan;
                            (iii) how to establish an advance 
                        directive;
                            (iv) procedures to help ensure that an 
                        individual's directives for end-of-life care 
                        are followed; and
                            (v) hospice and palliative care (including 
                        their respective purposes and services); and
                    (C) available Federal and State-specific resources 
                for assistance with advance care planning, including--
                            (i) contact information for any State 
                        public health departments that are responsible 
                        for issues regarding end-of-life care;
                            (ii) contact information for relevant legal 
                        service organizations, including those funded 
                        under the Older Americans Act of 1965 (42 
                        U.S.C. 3001 et seq.); and
                            (iii) advance directive forms for each 
                        State; and
                    (D) any additional information, as determined by 
                the Secretary.
    (b) Establishment of Pediatric Advance Care Planning 
Clearinghouse.--
            (1) Development.--Not later than January 1, 2011, the 
        Secretary, in consultation with the Assistant Secretary for 
        Children and Families of the Department of Health and Human 
        Services, shall develop an online clearinghouse to provide 
        comprehensive information regarding pediatric advance care 
        planning.
            (2) Maintenance.--The pediatric advance care planning 
        clearinghouse, which shall be clearly identifiable on the 
        homepage of the Administration for Children and Families 
        website, shall be maintained and publicized by the Secretary on 
        an ongoing basis.
            (3) Content.--The pediatric advance care planning 
        clearinghouse shall provide advance care planning information 
        specific to children with life-threatening illnesses or 
        injuries and their families.

SEC. 103. ADVANCE CARE PLANNING TOOLKIT.

    (a) Development.--Not later than July 1, 2010, the Secretary, in 
consultation with the Director of the Centers for Disease Control and 
Prevention, shall develop an online advance care planning toolkit.
    (b) Maintenance.--The advance care planning toolkit, which shall be 
available in English, Spanish, and any other languages that the 
Secretary deems appropriate, shall be maintained and publicized by the 
Secretary on an ongoing basis and made available on the following 
websites:
            (1) The Centers for Disease Control and Prevention.
            (2) The Department of Health and Human Service's National 
        Clearinghouse for Long-Term Care Information.
            (3) The Administration for Children and Families.
    (c) Content.--The advance care planning toolkit shall include 
content addressing--
            (1) common issues and questions regarding advance care 
        planning, including individuals and resources to contact for 
        further inquiries;
            (2) advance directives and their uses, including living 
        wills and durable powers of attorney;
            (3) the roles and responsibilities of a health care proxy;
            (4) Federal and State-specific resources to assist 
        individuals and their families with advance care planning, 
        including--
                    (A) the advance care planning toll-free telephone 
                hotline established under section 101;
                    (B) the advance care planning clearinghouses 
                established under section 102;
                    (C) the advance care planning toolkit established 
                under this section;
                    (D) available State legal service organizations to 
                assist individuals with advance care planning, 
                including those organizations that receive funding 
                pursuant to the Older Americans Act of 1965 (42 U.S.C. 
                3001 et seq.); and
                    (E) website links or addresses for State-specific 
                advance directive forms; and
            (5) any additional information, as determined by the 
        Secretary.

SEC. 104. NATIONAL PUBLIC EDUCATION CAMPAIGN.

    (a) National Public Education Campaign.--
            (1) In general.--Not later than January 1, 2011, the 
        Secretary, acting through the Director of the Centers for 
        Disease Control and Prevention, shall, directly or through 
        grants, contracts, or interagency agreements, develop and 
        implement a national campaign to inform the public of the 
        importance of advance care planning and of an individual's 
        right to direct and participate in their health care decisions.
            (2) Content of educational campaign.--The national public 
        education campaign established under paragraph (1) shall--
                    (A) employ the use of various media, including 
                regularly televised public service announcements;
                    (B) provide culturally and linguistically 
                appropriate information;
                    (C) be conducted continuously over a period of not 
                less than 5 years;
                    (D) identify and promote the advance care planning 
                information available on the Department of Health and 
                Human Service's National Clearinghouse for Long-Term 
                Care Information website and Administration for 
                Children and Families website, as well as any other 
                relevant Federal or State-specific advance care 
                planning resources;
                    (E) raise public awareness of the consequences that 
                may result if an individual is no longer able to 
                express or communicate their health care decisions;
                    (F) address the importance of individuals speaking 
                to family members, health care proxies, and health care 
                providers as part of an ongoing dialogue regarding 
                their health care choices;
                    (G) address the need for individuals to obtain 
                readily available legal documents that express their 
                health care decisions through advance directives 
                (including living wills, comfort care orders, and 
                durable powers of attorney for health care);
                    (H) raise public awareness regarding the 
                availability of hospice and palliative care; and
                    (I) encourage individuals to speak with their 
                physicians about their options and intentions for end-
                of-life care.
            (3) Evaluation.--
                    (A) In general.--Not later than July 1, 2013, the 
                Secretary, acting through the Director of the Centers 
                for Disease Control and Prevention, shall conduct a 
                nationwide survey to evaluate whether the national 
                campaign conducted under this subsection has achieved 
                its goal of changing public awareness, attitudes, and 
                behaviors regarding advance care planning.
                    (B) Baseline survey.--In order to evaluate the 
                effectiveness of the national campaign, the Secretary 
                shall conduct a baseline survey prior to implementation 
                of the campaign.
                    (C) Reporting requirement.--Not later than December 
                31, 2013, the Secretary shall report the findings of 
                such survey, as well as any recommendations that the 
                Secretary determines appropriate regarding the need for 
                continuation or legislative or administrative changes 
                to facilitate changing public awareness, attitudes, and 
                behaviors regarding advance care planning, to the 
                appropriate committees of the Congress.
    (b) Repeal.--Section 4751(d) of the Omnibus Budget Reconciliation 
Act of 1990 (42 U.S.C. 1396a note; Public Law 101-508) is repealed.

SEC. 105. UPDATE OF MEDICARE AND SOCIAL SECURITY HANDBOOKS.

    (a) Medicare & You Handbook.--
            (1) In general.--Not later than 60 days after the date of 
        enactment of this Act, the Secretary shall update the online 
        version of the ``Planning Ahead'' section of the Medicare & You 
        Handbook to include--
                    (A) an explanation of advance care planning and 
                advance directives, including--
                            (i) living wills;
                            (ii) health care proxies; and
                            (iii) after-death directives;
                    (B) Federal and State-specific resources to assist 
                individuals and their families with advance care 
                planning, including--
                            (i) the advance care planning toll-free 
                        telephone hotline established under section 
                        101;
                            (ii) the advance care planning 
                        clearinghouses established under section 102;
                            (iii) the advance care planning toolkit 
                        established under section 103;
                            (iv) available State legal service 
                        organizations to assist individuals with 
                        advance care planning, including those 
                        organizations that receive funding pursuant to 
                        the Older Americans Act of 1965 (42 U.S.C. 3001 
                        et seq.); and
                            (v) website links or addresses for State-
                        specific advance directive forms; and
                    (C) any additional information, as determined by 
                the Secretary.
            (2) Update of paper and subsequent versions.--The Secretary 
        shall include the information described in paragraph (1) in all 
        paper and electronic versions of the Medicare & You Handbook 
        that are published on or after the date that is 60 days after 
        the date of enactment of this Act.
    (b) Social Security Handbook.--The Commissioner of Social Security 
shall--
            (1) not later than 60 days after the date of enactment of 
        this Act, update the online version of the Social Security 
        Handbook for beneficiaries to include the information described 
        in subsection (a)(1); and
            (2) include such information in all paper and online 
        versions of such handbook that are published on or after the 
        date that is 60 days after the date of enactment of this Act.

SEC. 106. AUTHORIZATION OF APPROPRIATIONS.

    There is authorized to be appropriated for the period of fiscal 
years 2010 through 2014--
            (1) $195,000,000 to the Secretary to carry out sections 
        101, 102, 103, 104 and 105(a); and
            (2) $5,000,000 to the Commissioner of Social Security to 
        carry out section 105(b).

                 Subpart B--State and Local Initiatives

SEC. 111. FINANCIAL ASSISTANCE FOR ADVANCE CARE PLANNING.

    (a) Legal Assistance for Advance Care Planning.--
            (1) Definition of recipient.--Section 1002(6) of the Legal 
        Services Corporation Act (42 U.S.C. 2996a(6)) is amended by 
        striking ``clause (A) of'' and inserting ``subparagraph (A) or 
        (B) of''.
            (2) Advance care planning.--Section 1006 of the Legal 
        Services Corporation Act (42 U.S.C. 2996e) is amended--
                    (A) in subsection (a)(1)--
                            (i) by striking ``title, and (B) to make'' 
                        and inserting the following: ``title;
            ``(C) to make''; and
                            (ii) by inserting after subparagraph (A) 
                        the following:
            ``(B) to provide financial assistance, and make grants and 
        contracts, as described in subparagraph (A), on a competitive 
        basis for the purpose of providing legal assistance in the form 
        of advance care planning (as defined in section 3 of the 
        Advance Planning and Compassionate Care Act of 2009, and 
        including providing information about State-specific advance 
        directives, as defined in that section) for eligible clients 
        under this title, including providing such planning to the 
        family members of eligible clients and persons with power of 
        attorney to make health care decisions for the clients; and''; 
        and
                    (B) in subsection (b), by adding at the end the 
                following:
    ``(2) Advance care planning provided in accordance with subsection 
(a)(1)(B) shall not be construed to violate the Assisted Suicide 
Funding Restriction Act of 1997 (42 U.S.C. 14401 et seq.).''.
            (3) Reports.--Section 1008(a) of the Legal Services 
        Corporation Act (42 U.S.C. 2996g(a)) is amended by adding at 
        the end the following: ``The Corporation shall require such a 
        report, on an annual basis, from each grantee, contractor, or 
        other recipient of financial assistance under section 
        1006(a)(1)(B).''.
            (4) Authorization of appropriations.--Section 1010 of the 
        Legal Services Corporation Act (42 U.S.C. 2996i) is amended--
                    (A) in subsection (a)--
                            (i) by striking ``(a)'' and inserting 
                        ``(a)(1)'';
                            (ii) in the last sentence, by striking 
                        ``Appropriations for that purpose'' and 
                        inserting the following:
    ``(3) Appropriations for a purpose described in paragraph (1) or 
(2)''; and
                            (iii) by inserting before paragraph (3) (as 
                        designated by clause (ii)) the following:
    ``(2) There are authorized to be appropriated to carry out section 
1006(a)(1)(B), $10,000,000 for each of fiscal years 2010, 2011, 2012, 
2013, and 2014.''; and
                    (B) in subsection (d), by striking ``subsection 
                (a)'' and inserting ``subsection (a)(1)''.
            (5) Effective date.--This subsection and the amendments 
        made by this subsection take effect July 1, 2010.
    (b) State Health Insurance Assistance Programs.--
            (1) In general.--The Secretary shall use amounts made 
        available under paragraph (3) to award grants to States for 
        State health insurance assistance programs receiving assistance 
        under section 4360 of the Omnibus Budget Reconciliation Act of 
        1990 to provide advance care planning services to Medicare 
        beneficiaries, personal representatives of such beneficiaries, 
        and the families of such beneficiaries. Such services shall 
        include information regarding State-specific advance directives 
        and ways to discuss individual care wishes with health care 
        providers.
            (2) Requirements.--
                    (A) Award of grants.--In making grants under this 
                subsection for a fiscal year, the Secretary shall 
                satisfy the following requirements:
                            (i) Two-thirds of the total amount of funds 
                        available under paragraph (3) for a fiscal year 
                        shall be allocated among those States approved 
                        for a grant under this section that have 
                        adopted the Uniform Health-Care Decisions Act 
                        drafted by the National Conference of 
                        Commissioners on Uniform State Laws and 
                        approved and recommended for enactment by all 
                        States at the annual conference of such 
                        commissioners in 1993.
                            (ii) One-third of the total amount of funds 
                        available under paragraph (3) for a fiscal year 
                        shall be allocated among those States approved 
                        for a grant under this section that have 
                        adopted a uniform form for orders regarding 
                        life sustaining treatment as defined in section 
                        1861(hhh)(5) of the Social Security Act (as 
                        amended by section 211 of this Act) or a 
                        comparable approach to advance care planning.
                    (B) Work plan; report.--As a condition of being 
                awarded a grant under this subsection, a State shall 
                submit the following to the Secretary:
                            (i) An approved plan for expending grant 
                        funds.
                            (ii) For each fiscal year for which the 
                        State is paid grant funds under this 
                        subsection, an annual report regarding the use 
                        of the funds, including the number of Medicare 
                        beneficiaries served and their satisfaction 
                        with the services provided.
                    (C) Limitation.--No State shall be paid funds from 
                a grant made under this subsection prior to July 1, 
                2010.
            (3) Authorization of appropriations.--There is authorized 
        to be appropriated to the Secretary to the Centers for Medicare 
        & Medicaid Services Program Management Account, $12,000,000 for 
        each of fiscal years 2010 through 2014 for purposes of awarding 
        grants to States under paragraph (1).
    (c) Medicaid Transformation Grants for Advance Care Planning.--
Section 1903(z) of the Social Security Act (42 U.S.C. 1396b(z)) is 
amended--
            (1) in paragraph (2), by adding at the end the following 
        new subparagraph:
                    ``(G) Methods for improving the effectiveness and 
                efficiency of medical assistance provided under this 
                title by making available to individuals enrolled in 
                the State plan or under a waiver of such plan 
                information regarding advance care planning (as defined 
                in section 3 of the Advance Planning and Compassionate 
                Care Act of 2009), including at time of enrollment or 
                renewal of enrollment in the plan or waiver, through 
                providers, and through such other innovative means as 
                the State determines appropriate.'';
            (2) in paragraph (3), by adding at the end the following 
        new subparagraph:
                    ``(D) Work plan required for award of advance care 
                planning grants.--Payment to a State under this 
                subsection to adopt the innovative methods described in 
                paragraph (2)(G) is conditioned on the State submitting 
                to the Secretary an approved plan for expending the 
                funds awarded to the State under this subsection.''; 
                and
            (3) in paragraph (4)--
                    (A) in subparagraph (A)--
                            (i) in clause (i), by striking ``and'' at 
                        the end;
                            (ii) in clause (ii), by striking the period 
                        at the end and inserting ``; and''; and
                            (iii) by inserting after clause (ii), the 
                        following new clause:
                            ``(iii) $20,000,000 for each of fiscal 
                        years 2010 through 2014.''; and
                    (B) by striking subparagraph (B), and inserting the 
                following:
                    ``(B) Allocation of funds.--The Secretary shall 
                specify a method for allocating the funds made 
                available under this subsection among States awarded a 
                grant for fiscal year 2010, 2011, 2012, 2013, or 2014. 
                Such method shall provide that--
                            ``(i) 100 percent of such funds for each of 
                        fiscal years 2010 through 2014 shall be awarded 
                        to States that design programs to adopt the 
                        innovative methods described in paragraph 
                        (2)(G); and
                            ``(ii) in no event shall a payment to a 
                        State awarded a grant under this subsection for 
                        fiscal year 2010 be made prior to July 1, 
                        2010.''.
    (d) Advance Care Planning Community Training Grants.--
            (1) In general.--The Secretary shall use amounts made 
        available under paragraph (3) to award grants to area agencies 
        on aging (as defined in section 102 of the Older Americans Act 
        of 1965 (42 U.S.C. 3002)).
            (2) Requirements.--
                    (A) Use of funds.--Funds awarded to an area agency 
                on aging under this subsection shall be used to provide 
                advance care planning education and training 
                opportunities for local aging service providers and 
                organizations.
                    (B) Work plan; report.--As a condition of being 
                awarded a grant under this subsection, an area agency 
                on aging shall submit the following to the Secretary:
                            (i) An approved plan for expending grant 
                        funds.
                            (ii) For each fiscal year for which the 
                        agency is paid grant funds under this 
                        subsection, an annual report regarding the use 
                        of the funds, including the number of Medicare 
                        beneficiaries served and their satisfaction 
                        with the services provided.
                    (C) Limitation.--No area agency on aging shall be 
                paid funds from a grant made under this subsection 
                prior to July 1, 2010.
            (3) Authorization of appropriations.--There is authorized 
        to be appropriated to the Secretary to the Centers for Medicare 
        & Medicaid Services Program Management Account, $12,000,000 for 
        each of fiscal years 2010 through 2014 for purposes of awarding 
        grants to area agencies on aging under paragraph (1).
    (e) Nonduplication of Activities.--The Secretary shall establish 
procedures to ensure that funds made available under grants awarded 
under this section or pursuant to amendments made by this section 
supplement, not supplant, existing Federal funding, and that such funds 
are not used to duplicate activities carried out under such grants or 
under other Federally funded programs.

SEC. 112. GRANTS FOR PROGRAMS FOR ORDERS REGARDING LIFE SUSTAINING 
              TREATMENT.

    (a) In General.--The Secretary shall make grants to eligible 
entities for the purpose of--
            (1) establishing new programs for orders regarding life 
        sustaining treatment in States or localities;
            (2) expanding or enhancing an existing program for orders 
        regarding life sustaining treatment in States or localities; or
            (3) providing a clearinghouse of information on programs 
        for orders for life sustaining treatment and consultative 
        services for the development or enhancement of such programs.
    (b) Authorized Activities.--Activities funded through a grant under 
this section for an area may include--
            (1) developing such a program for the area that includes 
        home care, hospice, long-term care, community and assisted 
        living residences, skilled nursing facilities, inpatient 
        rehabilitation facilities, hospitals, and emergency medical 
        services within the area;
            (2) securing consultative services and advice from 
        institutions with experience in developing and managing such 
        programs; and
            (3) expanding an existing program for orders regarding life 
        sustaining treatment to serve more patients or enhance the 
        quality of services, including educational services for 
        patients and patients' families or training of health care 
        professionals.
    (c) Distribution of Funds.--In funding grants under this section, 
the Secretary shall ensure that, of the funds appropriated to carry out 
this section for each fiscal year--
            (1) at least two-thirds are used for establishing or 
        developing new programs for orders regarding life sustaining 
        treatment; and
            (2) one-third is used for expanding or enhancing existing 
        programs for orders regarding life sustaining treatment.
    (d) Definitions.--In this section:
            (1) The term ``eligible entity'' includes--
                    (A) an academic medical center, a medical school, a 
                State health department, a State medical association, a 
                multi-State taskforce, a hospital, or a health system 
                capable of administering a program for orders regarding 
                life sustaining treatment for a State or locality; or
                    (B) any other health care agency or entity as the 
                Secretary determines appropriate.
            (2) The term ``order regarding life sustaining treatment'' 
        has the meaning given such term in section 1861(hhh)(5) of the 
        Social Security Act, as added by section 211.
            (3) The term ``program for orders regarding life sustaining 
        treatment'' means, with respect to an area, a program that 
        supports the active use of orders regarding life sustaining 
        treatment in the area.
    (e) Authorization of Appropriations.--To carry out this section, 
there are authorized to be appropriated such sums as may be necessary 
for each of the fiscal years 2009 through 2014.

                      PART II--PROVIDER EDUCATION

SEC. 121. PUBLIC PROVIDER ADVANCE CARE PLANNING WEBSITE.

    (a) Development.--Not later than January 1, 2010, the Secretary, 
acting through the Administrator of the Centers for Medicare & Medicaid 
Services and the Director of the Agency for Healthcare Research and 
Quality, shall establish a website for providers under Medicare, 
Medicaid, the Children's Health Insurance Program, the Indian Health 
Service (include contract providers) and other public health providers 
on each individual's right to make decisions concerning medical care, 
including the right to accept or refuse medical or surgical treatment, 
and the existence of advance directives.
    (b) Maintenance.--The website, shall be maintained and publicized 
by the Secretary on an ongoing basis.
    (c) Content.--The website shall include content, tools, and 
resources necessary to do the following:
            (1) Inform providers about the advance directive 
        requirements under the health care programs described in 
        subsection (a) and other State and Federal laws and regulations 
        related to advance care planning.
            (2) Educate providers about advance care planning quality 
        improvement activities.
            (3) Provide assistance to providers to--
                    (A) integrate advance directives into electronic 
                health records, including oral directives; and
                    (B) develop and disseminate advance care planning 
                informational materials for their patients.
            (4) Inform providers about advance care planning continuing 
        education requirements and opportunities.
            (5) Encourage providers to discuss advance care planning 
        with their patients of all ages.
            (6) Assist providers' understanding of the continuum of 
        end-of-life care services and supports available to patients, 
        including palliative care and hospice.
            (7) Inform providers of best practices for discussing end-
        of-life care with dying patients and their loved ones.

SEC. 122. CONTINUING EDUCATION FOR PHYSICIANS AND NURSES.

    (a) In General.--Not later than January 1, 2012, the Secretary, 
acting through the Director of Health Resources and Services 
Administration, shall develop, in consultation with health care 
providers and State boards of medicine and nursing, a curriculum for 
continuing education that States may adopt for physicians and nurses on 
advance care planning and end-of-life care.
    (b) Content.--
            (1) In general.--The continuing education curriculum 
        developed under subsection (a) for physicians and nurses shall, 
        at a minimum, include--
                    (A) a description of the meaning and importance of 
                advance care planning;
                    (B) a description of advance directives, including 
                living wills and durable powers of attorney, and the 
                use of such directives;
                    (C) palliative care principles and approaches to 
                care; and
                    (D) the continuum of end-of-life services and 
                supports, including palliative care and hospice.
            (2) Additional content for physicians.--The continuing 
        education curriculum for physicians developed under subsection 
        (a) shall include instruction on how to conduct advance care 
        planning with patients and their loved ones.

   Subtitle B--Portability of Advance Directives; Health Information 
                               Technology

SEC. 131. PORTABILITY OF ADVANCE DIRECTIVES.

    (a) Medicare.--Section 1866(f) of the Social Security Act (42 
U.S.C. 1395cc(f)) is amended--
            (1) in paragraph (1)--
                    (A) in subparagraph (B), by inserting ``and if 
                presented by the individual, to include the content of 
                such advance directive in a prominent part of such 
                record'' before the semicolon at the end;
                    (B) in subparagraph (D), by striking ``and'' after 
                the semicolon at the end;
                    (C) in subparagraph (E), by striking the period at 
                the end and inserting ``; and''; and
                    (D) by inserting after subparagraph (E) the 
                following new subparagraph:
            ``(F) to provide each individual with the opportunity to 
        discuss issues relating to the information provided to that 
        individual pursuant to subparagraph (A) with an appropriately 
        trained professional.'';
            (2) in paragraph (3), by striking ``a written'' and 
        inserting ``an''; and
            (3) by adding at the end the following new paragraph:
    ``(5)(A) An advance directive validly executed outside of the State 
in which such advance directive is presented by an adult individual to 
a provider of services, a Medicare Advantage organization, or a prepaid 
or eligible organization shall be given the same effect by that 
provider or organization as an advance directive validly executed under 
the law of the State in which it is presented would be given effect.
    ``(B)(i) The definition of an advanced directive shall also include 
actual knowledge of instructions made while an individual was able to 
express the wishes of such individual with regard to health care.
    ``(ii) For purposes of clause (i), the term `actual knowledge' 
means the possession of information of an individual's wishes 
communicated to the health care provider orally or in writing by the 
individual, the individual's medical power of attorney representative, 
the individual's health care surrogate, or other individuals resulting 
in the health care provider's personal cognizance of these wishes. 
Other forms of imputed knowledge are not actual knowledge.
    ``(C) The provisions of this paragraph shall preempt any State law 
to the extent such law is inconsistent with such provisions. The 
provisions of this paragraph shall not preempt any State law that 
provides for greater portability, more deference to a patient's wishes, 
or more latitude in determining a patient's wishes.''.
    (b) Medicaid.--Section 1902(w) of the Social Security Act (42 
U.S.C. 1396a(w)) is amended--
            (1) in paragraph (1)--
                    (A) in subparagraph (B)--
                            (i) by striking ``in the individual's 
                        medical record'' and inserting ``in a prominent 
                        part of the individual's current medical 
                        record''; and
                            (ii) by inserting ``and if presented by the 
                        individual, to include the content of such 
                        advance directive in a prominent part of such 
                        record'' before the semicolon at the end;
                    (B) in subparagraph (D), by striking ``and'' after 
                the semicolon at the end;
                    (C) in subparagraph (E), by striking the period at 
                the end and inserting ``; and''; and
                    (D) by inserting after subparagraph (E) the 
                following new subparagraph:
            ``(F) to provide each individual with the opportunity to 
        discuss issues relating to the information provided to that 
        individual pursuant to subparagraph (A) with an appropriately 
        trained professional.'';
            (2) in paragraph (4), by striking ``a written'' and 
        inserting ``an''; and
            (3) by adding at the end the following paragraph:
    ``(6)(A) An advance directive validly executed outside of the State 
in which such advance directive is presented by an adult individual to 
a provider or organization shall be given the same effect by that 
provider or organization as an advance directive validly executed under 
the law of the State in which it is presented would be given effect.
    ``(B)(i) The definition of an advance directive shall also include 
actual knowledge of instructions made while an individual was able to 
express the wishes of such individual with regard to health care.
    ``(ii) For purposes of clause (i), the term `actual knowledge' 
means the possession of information of an individual's wishes 
communicated to the health care provider orally or in writing by the 
individual, the individual's medical power of attorney representative, 
the individual's health care surrogate, or other individuals resulting 
in the health care provider's personal cognizance of these wishes. 
Other forms of imputed knowledge are not actual knowledge.
    ``(C) The provisions of this paragraph shall preempt any State law 
to the extent such law is inconsistent with such provisions. The 
provisions of this paragraph shall not preempt any State law that 
provides for greater portability, more deference to a patient's wishes, 
or more latitude in determining a patient's wishes.''.
    (c) CHIP.--Section 2107(e)(1) of the Social Security Act (42 U.S.C. 
1397gg(e)(1)) is amended--
            (1) by redesignating subparagraphs (E) through (L) as 
        subparagraphs (D) through (M), respectively; and
            (2) by inserting after subparagraph (D) the following:
                    ``(E) Section 1902(w) (relating to advance 
                directives).''.
    (d) Study and Report Regarding Implementation.--
            (1) Study.--The Secretary shall conduct a study regarding 
        the implementation of the amendments made by subsections (a) 
        and (b).
            (2) Report.--Not later than 18 months after the date of 
        enactment of this Act, the Secretary shall submit to Congress a 
        report on the study conducted under paragraph (1), together 
        with recommendations for such legislation and administrative 
        actions as the Secretary considers appropriate.
    (e) Effective Dates.--
            (1) In general.--Subject to paragraph (2), the amendments 
        made by subsections (a), (b), and (c) shall apply to provider 
        agreements and contracts entered into, renewed, or extended 
        under title XVIII of the Social Security Act (42 U.S.C. 1395 et 
        seq.), and to State plans under title XIX of such Act (42 
        U.S.C. 1396 et seq.) and State child health plans under title 
        XXI of such Act (42 U.S.C. 1397aa et seq.), on or after such 
        date as the Secretary specifies, but in no case may such date 
        be later than 1 year after the date of enactment of this Act.
            (2) Extension of effective date for state law amendment.--
        In the case of a State plan under title XIX of the Social 
        Security Act or a State child health plan under title XXI of 
        such Act which the Secretary determines requires State 
        legislation in order for the plan to meet the additional 
        requirements imposed by the amendments made by subsections (b) 
        and (c), the State plan shall not be regarded as failing to 
        comply with the requirements of such title solely on the basis 
        of its failure to meet these additional requirements before the 
        first day of the first calendar quarter beginning after the 
        close of the first regular session of the State legislature 
        that begins after the date of enactment of this Act. For 
        purposes of the previous sentence, in the case of a State that 
        has a 2-year legislative session, each year of the session is 
        considered to be a separate regular session of the State 
        legislature.

SEC. 132. STATE ADVANCE DIRECTIVE REGISTRIES; DRIVER'S LICENSE ADVANCE 
              DIRECTIVE NOTATION.

    Part P of title III of the Public Health Service Act (42 U.S.C. 
280g) is amended--
            (1) by redesignating section 399R (as inserted by section 2 
        of Public Law 110-373) as section 399S;
            (2) by redesignating section 399R (as inserted by section 3 
        of Public Law 110-374) as section 399T; and
            (3) by adding at the end the following:

``SEC. 399U. STATE ADVANCE DIRECTIVE REGISTRIES.

    ``(a) State Advance Directive Registry.--In this section, the term 
`State advance directive registry' means a secure, electronic database 
that--
            ``(1) is available free of charge to residents of a State; 
        and
            ``(2) stores advance directive documents and makes such 
        documents accessible to medical service providers in accordance 
        with Federal and State privacy laws.
    ``(b) Grant Program.--Beginning on July 1, 2010, the Secretary, 
acting through the Director of the Centers for Disease Control and 
Prevention, shall award grants on a competitive basis to eligible 
entities to establish and operate, directly or indirectly (by 
competitive grant or competitive contract), State advance directive 
registries.
    ``(c) Eligible Entities.--
            ``(1) In general.--To be eligible to receive a grant under 
        this section, an entity shall--
                    ``(A) be a State department of health; and
                    ``(B) submit to the Director an application at such 
                time, in such manner, and containing--
                            ``(i) a plan for the establishment and 
                        operation of a State advance directive 
                        registry; and
                            ``(ii) such other information as the 
                        Director may require.
            ``(2) No requirement of notation mechanism.--The Secretary 
        shall not require that an entity establish and operate a 
        driver's license advance directive notation mechanism for State 
        residents under section 399V to be eligible to receive a grant 
        under this section.
    ``(d) Annual Report.--For each year for which an entity receives an 
award under this section, such entity shall submit an annual report to 
the Director on the use of the funds received pursuant to such award, 
including the number of State residents served through the registry.
    ``(e) Authorization.--There is authorized to be appropriated to 
carry out this section $20,000,000 for fiscal year 2010 and each fiscal 
year thereafter.

``SEC. 399V. DRIVER'S LICENSE ADVANCE DIRECTIVE NOTATION.

    ``(a) In General.--Beginning July 1, 2010, the Secretary, acting 
through the Director of the Centers for Disease Control and Prevention, 
shall award grants on a competitive basis to States to establish and 
operate a mechanism for a State resident with a driver's license to 
include a notice of the existence of an advance directive for such 
resident on such license.
    ``(b) Eligibility.--To be eligible to receive a grant under this 
section, a State shall--
            ``(1) establish and operate a State advance directive 
        registry under section 399U; and
            ``(2) submit to the Director an application at such time, 
        in such manner, and containing--
                    ``(A) a plan that includes a description of how the 
                State will--
                            ``(i) disseminate information about advance 
                        directives at the time of driver's license 
                        application or renewal;
                            ``(ii) enable each State resident with a 
                        driver's license to include a notice of the 
                        existence of an advance directive for such 
                        resident on such license in a manner consistent 
                        with the notice on such a license indicating a 
                        driver's intent to be an organ donor; and
                            ``(iii) coordinate with the State 
                        department of health to ensure that, if a State 
                        resident has an advance directive notice on his 
                        or her driver's license, the existence of such 
                        advance directive is included in the State 
                        registry established under section 399U; and
                    ``(B) any other information as the Director may 
                require.
    ``(c) Annual Report.--For each year for which a State receives an 
award under this section, such State shall submit an annual report to 
the Director on the use of the funds received pursuant to such award, 
including the number of State residents served through the mechanism.
    ``(d) Authorization.--There is authorized to be appropriated to 
carry out this section $50,000,000 for fiscal year 2010 and each fiscal 
year thereafter.''.

SEC. 133. GAO STUDY AND REPORT ON ESTABLISHMENT OF NATIONAL ADVANCE 
              DIRECTIVE REGISTRY.

    (a) Study.--The Comptroller General of the United States shall 
conduct a study on the feasibility of a national registry for advance 
directives, taking into consideration the constraints created by the 
privacy provisions enacted as a result of the Health Insurance 
Portability and Accountability Act of 1996 (Public Law 104-191).
    (b) Report.--Not later than 18 months after the date of enactment 
of this Act, the Comptroller General of the United States shall submit 
to Congress a report on the study conducted under subsection (a) 
together with recommendations for such legislation and administrative 
action as the Comptroller General of the United States determines to be 
appropriate.

      Subtitle C--National Uniform Policy on Advance Care Planning

SEC. 141. STUDY AND REPORT BY THE SECRETARY REGARDING THE ESTABLISHMENT 
              AND IMPLEMENTATION OF A NATIONAL UNIFORM POLICY ON 
              ADVANCE DIRECTIVES.

    (a) Study.--
            (1) In general.--The Secretary, acting through the Office 
        of the Assistant Secretary for Planning and Evaluation, shall 
        conduct a thorough study of all matters relating to the 
        establishment and implementation of a national uniform policy 
        on advance directives for individuals receiving items and 
        services under titles XVIII, XIX, or XXI of the Social Security 
        Act (42 U.S.C. 1395 et seq.; 1396 et seq.; 1397aa et seq.).
            (2) Matters studied.--The matters studied by the Secretary 
        under paragraph (1) shall include issues concerning--
                    (A) family satisfaction that a patient's wishes, as 
                stated in the patient's advance directive, were carried 
                out;
                    (B) the portability of advance directives, 
                including cases involving the transfer of an individual 
                from 1 health care setting to another;
                    (C) immunity from civil liability and criminal 
                responsibility for health care providers that follow 
                the instructions in an individual's advance directive 
                that was validly executed in, and consistent with the 
                laws of, the State in which it was executed;
                    (D) conditions under which an advance directive is 
                operative;
                    (E) revocation of an advance directive by an 
                individual;
                    (F) the criteria used by States for determining 
                that an individual has a terminal condition;
                    (G) surrogate decisionmaking regarding end-of-life 
                care;
                    (H) the provision of adequate palliative care (as 
                defined in paragraph (3)), including pain management;
                    (I) adequate and timely referrals to hospice care 
                programs; and
                    (J) the end-of-life care needs of children and 
                their families.
            (3) Palliative care.--For purposes of paragraph (2)(H), the 
        term ``palliative care'' means interdisciplinary care for 
        individuals with a life-threatening illness or injury relating 
        to pain and symptom management and psychological, social, and 
        spiritual needs and that seeks to improve the quality of life 
        for the individual and the individual's family.
    (b) Report to Congress.--Not later than 18 months after the date of 
enactment of this Act, the Secretary shall submit to Congress a report 
on the study conducted under subsection (a), together with 
recommendations for such legislation and administrative actions as the 
Secretary considers appropriate.
    (c) Consultation.--In conducting the study and developing the 
report under this section, the Secretary shall consult with the Uniform 
Law Commissioners, and other interested parties.

                      TITLE II--COMPASSIONATE CARE

                   Subtitle A--Workforce Development

                     PART I--EDUCATION AND TRAINING

SEC. 201. NATIONAL GERIATRIC AND PALLIATIVE CARE SERVICES CORPS.

    Section 331 of the Public Health Service Act (42 U.S.C. 254d) is 
amended--
            (1) by redesignating subsection (j) as subsection (k); and
            (2) by inserting after subsection (i), the following:
    ``(j) National Geriatric and Palliative Care Services Corps.--
            ``(1) Establishment.--Not later than January 1, 2012, the 
        Secretary shall establish within the National Health Service 
        Corps a National Geriatric and Palliative Care Services Corps 
        (referred to in this subsection as the `Corps') which shall 
        consist of--
                    ``(A) such officers of the Regular and Reserve 
                Corps of the Service as the Secretary may designate;
                    ``(B) such civilian employees of the United States 
                as the Secretary may appoint; and
                    ``(C) such other individuals who are not employees 
                of the United States.
            ``(2) Duties.--The Corps shall be utilized by the Secretary 
        to provide geriatric and palliative care services within health 
        professional shortage areas.
            ``(3) Application of provisions.--The loan-forgiveness, 
        scholarship, and direct financial incentives programs provided 
        for under this section shall apply to physicians, nurses, and 
        other health professionals (as identified by the Secretary) 
        with respect to the training necessary to enable such 
        individuals to become geriatric or palliative care specialists 
        and provide geriatric and palliative care services in health 
        professional shortage areas.
            ``(4) Report.--Not later than 6 months prior to the date on 
        which the Secretary establishes the Corps under paragraph (1), 
        the Secretary shall submit to Congress a report concerning the 
        organization of the Corps, the application process for 
        membership in the Corps, and the funding necessary for the 
        Corps (targeted by profession and by specialization).''.

SEC. 202. EXEMPTION OF PALLIATIVE MEDICINE FELLOWSHIP TRAINING FROM 
              MEDICARE GRADUATE MEDICAL EDUCATION CAPS.

    (a) Direct Graduate Medical Education.--Section 1886(h)(4)(F) of 
the Social Security Act (42 U.S.C. 1395ww(h)(4)(F)) is amended--
            (1) in clause (i), by inserting ``clause (iii) and'' after 
        ``subject to''; and
            (2) by adding at the end the following new clause:
                            ``(iii) Increase allowed for palliative 
                        medicine fellowship training.--For cost 
                        reporting periods beginning on or after January 
                        1, 2011, in applying clause (i), there shall 
                        not be taken into account full-time equivalent 
                        residents in the field of allopathic or 
                        osteopathic medicine who are in palliative 
                        medicine fellowship training that is approved 
                        by the Accreditation Council for Graduate 
                        Medical Education.''.
    (b) Indirect Medical Education.--Section 1886(d)(5)(B) of the 
Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by adding at 
the end the following new clause:
            ``(x) Clause (iii) of subsection (h)(4)(F) shall apply to 
        clause (v) in the same manner and for the same period as such 
        clause (iii) applies to clause (i) of such subsection.''.

SEC. 203. MEDICAL SCHOOL CURRICULA.

    (a) In General.--The Secretary, in consultation with the 
Association of American Medical Colleges, shall establish guidelines 
for the imposition by medical schools of a minimum amount of end-of-
life training as a requirement for obtaining a Doctor of Medicine 
degree in the field of allopathic or osteopathic medicine.
    (b) Training.--Under the guidelines established under subsection 
(a), minimum training shall include--
            (1) training in how to discuss and help patients and their 
        loved ones with advance care planning;
            (2) with respect to students and trainees who will work 
        with children, specialized pediatric training;
            (3) training in the continuum of end-of-life services and 
        supports, including palliative care and hospice;
            (4) training in how to discuss end-of-life care with dying 
        patients and their loved ones; and
            (5) medical and legal issues training.
    (c) Distribution.--Not later than January 1, 2011, the Secretary 
shall disseminate the guidelines established under subsection (a) to 
medical schools.
    (d) Compliance.--Effective beginning not later than July 1, 2012, a 
medical school that is receiving Federal assistance shall be required 
to implement the guidelines established under subsection (a). A medical 
school that the Secretary determines is not implementing such 
guidelines shall not be eligible for Federal assistance.

        Subtitle B--Coverage Under Medicare, Medicaid, and CHIP

               PART I--COVERAGE OF ADVANCE CARE PLANNING

SEC. 211. MEDICARE, MEDICAID, AND CHIP COVERAGE.

    (a) Medicare.--
            (1) In general.--Section 1861 of the Social Security Act 
        (42 U.S.C. 1395x) is amended--
                    (A) in subsection (s)(2)--
                            (i) by striking ``and'' at the end of 
                        subparagraph (DD);
                            (ii) by adding ``and'' at the end of 
                        subparagraph (EE); and
                            (iii) by adding at the end the following 
                        new subparagraph:
                    ``(FF) advance care planning consultation (as 
                defined in subsection (hhh)(1));''; and
                    (B) by adding at the end the following new 
                subsection:

                  ``Advance Care Planning Consultation

    ``(hhh)(1) Subject to paragraphs (3) and (4), the term `advance 
care planning consultation' means a consultation between the individual 
and a practitioner described in paragraph (2) regarding advance care 
planning, if, subject to subparagraphs (A) and (B) of paragraph (3), 
the individual involved has not had such a consultation within the last 
5 years. Such consultation shall include the following:
            ``(A) An explanation by the practitioner of advance care 
        planning, including key questions and considerations, important 
        steps, and suggested people to talk to.
            ``(B) An explanation by the practitioner of advance 
        directives, including living wills and durable powers of 
        attorney, and their uses.
            ``(C) An explanation by the practitioner of the role and 
        responsibilities of a health care proxy.
            ``(D) The provision by the practitioner of a list of 
        national and State-specific resources to assist consumers and 
        their families with advance care planning, including the 
        national toll-free hotline, the advance care planning 
        clearinghouses, and State legal service organizations 
        (including those funded through the Older Americans Act).
            ``(E) An explanation by the practitioner of the continuum 
        of end-of-life services and supports available, including 
        palliative care and hospice, and benefits for such services and 
        supports that are available under this title.
            ``(F)(i) Subject to clause (ii), an explanation of orders 
        regarding life sustaining treatment or similar orders, which 
        shall include--
                    ``(I) the reasons why the development of such an 
                order is beneficial to the individual and the 
                individual's family and the reasons why such an order 
                should be updated periodically as the health of the 
                individual changes;
                    ``(II) the information needed for an individual or 
                legal surrogate to make informed decisions regarding 
                the completion of such an order; and
                    ``(III) the identification of resources that an 
                individual may use to determine the requirements of the 
                State in which such individual resides so that the 
                treatment wishes of that individual will be carried out 
                if the individual is unable to communicate those 
                wishes, including requirements regarding the 
                designation of a surrogate decisionmaker (also known as 
                a health care proxy).
            ``(ii) The Secretary may limit the requirement for 
        explanations under clause (i) to consultations furnished in 
        States, localities, or other geographic areas in which orders 
        described in such clause have been widely adopted.
    ``(2) A practitioner described in this paragraph is--
            ``(A) a physician (as defined in subsection (r)(1)); and
            ``(B) a nurse practitioner or physician's assistant who has 
        the authority under State law to sign orders for life 
        sustaining treatments.
    ``(3)(A) An initial preventive physical examination under 
subsection (ww), including any related discussion during such 
examination, shall not be considered an advance care planning 
consultation for purposes of applying the 5-year limitation under 
paragraph (1).
    ``(B) An advance care planning consultation with respect to an 
individual shall be conducted more frequently than provided under 
paragraph (1) if there is a significant change in the health condition 
of the individual, including diagnosis of a chronic, progressive, life-
limiting disease, a life-threatening or terminal diagnosis or life-
threatening injury, or upon admission to a skilled nursing facility, a 
long-term care facility (as defined by the Secretary), or a hospice 
program.
    ``(4) A consultation under this subsection may include the 
formulation of an order regarding life sustaining treatment or a 
similar order.
    ``(5)(A) For purposes of this section, the term `order regarding 
life sustaining treatment' means, with respect to an individual, an 
actionable medical order relating to the treatment of that individual 
that--
            ``(i) is signed and dated by a physician (as defined in 
        subsection (r)(1)) or another health care professional (as 
        specified by the Secretary and who is acting within the scope 
        of the professional's authority under State law in signing such 
        an order) and is in a form that permits it to stay with the 
        patient and be followed by health care professionals and 
        providers across the continuum of care, including home care, 
        hospice, long-term care, community and assisted living 
        residences, skilled nursing facilities, inpatient 
        rehabilitation facilities, hospitals, and emergency medical 
        services;
            ``(ii) effectively communicates the individual's 
        preferences regarding life sustaining treatment, including an 
        indication of the treatment and care desired by the individual;
            ``(iii) is uniquely identifiable and standardized within a 
        given locality, region, or State (as identified by the 
        Secretary);
            ``(iv) is portable across care settings; and
            ``(v) may incorporate any advance directive (as defined in 
        section 1866(f)(3)) if executed by the individual.
    ``(B) The level of treatment indicated under subparagraph (A)(ii) 
may range from an indication for full treatment to an indication to 
limit some or all or specified interventions. Such indicated levels of 
treatment may include indications respecting, among other items--
            ``(i) the intensity of medical intervention if the patient 
        is pulseless, apneic, or has serious cardiac or pulmonary 
        problems;
            ``(ii) the individual's desire regarding transfer to a 
        hospital or remaining at the current care setting;
            ``(iii) the use of antibiotics; and
            ``(iv) the use of artificially administered nutrition and 
        hydration.''.
            (2) Payment.--Section 1848(j)(3) of the Social Security Act 
        (42 U.S.C. 1395w-4(j)(3)) is amended by inserting ``(2)(FF),'' 
        after ``(2)(EE),''.
            (3) Frequency limitation.--Section 1862(a) of the Social 
        Security Act (42 U.S.C. 1395y(a)(1)) is amended--
                    (A) in paragraph (1)--
                            (i) in subparagraph (N), by striking 
                        ``and'' at the end;
                            (ii) in subparagraph (O) by striking the 
                        semicolon at the end and inserting ``, and''; 
                        and
                            (iii) by adding at the end the following 
                        new subparagraph:
            ``(P) in the case of advance care planning consultations 
        (as defined in section 1861(hhh)(1)), which are performed more 
        frequently than is covered under such section;''; and
                    (B) in paragraph (7), by striking ``or (K)'' and 
                inserting ``(K), or (P)''.
            (4) Effective date.--The amendments made by this subsection 
        shall apply to consultations furnished on or after January 1, 
        2011.
    (b) Medicaid.--
            (1) Mandatory benefit.--Section 1902(a)(10)(A) of the 
        Social Security Act (42 U.S.C. 1396a(a)(10)(A)) is amended in 
        the matter preceding clause (i) by striking ``and (21)'' and 
        inserting ``, (21), and (28)''.
            (2) Medical assistance.--Section 1905 of such Act (42 
        U.S.C. 1396d) is amended--
                    (A) in subsection (a)--
                            (i) in paragraph (27), by striking ``and'' 
                        at the end;
                            (ii) by redesignating paragraph (28) as 
                        paragraph (29); and
                            (iii) by inserting after paragraph (27) the 
                        following new paragraph:
            ``(28) advance care planning consultations (as defined in 
        subsection (y));''; and
                    (B) by adding at the end the following:
    ``(y)(1) For purposes of subsection (a)(28), the term `advance care 
planning consultation' means a consultation between the individual and 
a practitioner described in paragraph (2) regarding advance care 
planning, if, subject to paragraph (3), the individual involved has not 
had such a consultation within the last 5 years. Such consultation 
shall include the following:
            ``(A) An explanation by the practitioner of advance care 
        planning, including key questions and considerations, important 
        steps, and suggested people to talk to.
            ``(B) An explanation by the practitioner of advance 
        directives, including living wills and durable powers of 
        attorney, and their uses.
            ``(C) An explanation by the practitioner of the role and 
        responsibilities of a health care proxy.
            ``(D) The provision by the practitioner of a list of 
        national and State-specific resources to assist consumers and 
        their families with advance care planning, including the 
        national toll-free hotline, the advance care planning 
        clearinghouses, and State legal service organizations 
        (including those funded through the Older Americans Act).
            ``(E) An explanation by the practitioner of the continuum 
        of end-of-life services and supports available, including 
        palliative care and hospice, and benefits for such services and 
        supports that are available under this title.
            ``(F)(i) Subject to clause (ii), an explanation of orders 
        for life sustaining treatments or similar orders, which shall 
        include--
                    ``(I) the reasons why the development of such an 
                order is beneficial to the individual and the 
                individual's family and the reasons why such an order 
                should be updated periodically as the health of the 
                individual changes;
                    ``(II) the information needed for an individual or 
                legal surrogate to make informed decisions regarding 
                the completion of such an order; and
                    ``(III) the identification of resources that an 
                individual may use to determine the requirements of the 
                State in which such individual resides so that the 
                treatment wishes of that individual will be carried out 
                if the individual is unable to communicate those 
                wishes, including requirements regarding the 
                designation of a surrogate decisionmaker (also known as 
                a health care proxy).
            ``(ii) The Secretary may limit the requirement for 
        explanations under clause (i) to consultations furnished in 
        States, localities, or other geographic areas in which orders 
        described in such clause have been widely adopted.
    ``(2) A practitioner described in this paragraph is--
            ``(A) a physician (as defined in section 1861(r)(1)); and
            ``(B) a nurse practitioner or physician's assistant who has 
        the authority under State law to sign orders for life 
        sustaining treatments.
    ``(3) An advance care planning consultation with respect to an 
individual shall be conducted more frequently than provided under 
paragraph (1) if there is a significant change in the health condition 
of the individual including diagnosis of a chronic, progressive, life-
limiting disease, a life-threatening or terminal diagnosis or life-
threatening injury, or upon admission to a nursing facility, a long-
term care facility (as defined by the Secretary), or a hospice program.
    ``(4) A consultation under this subsection may include the 
formulation of an order regarding life sustaining treatment or a 
similar order.
    ``(5) For purposes of this subsection, the term `orders regarding 
life sustaining treatment' has the meaning given that term in section 
1861(hhh)(5).''.
    (c) CHIP.--
            (1) Child health assistance.--Section 2110(a) of the Social 
        Security Act (42 U.S.C. 1397jj) is amended--
                    (A) by redesignating paragraph (28) as paragraph 
                (29); and
                    (B) by inserting after paragraph (27), the 
                following:
            ``(28) Advance care planning consultations (as defined in 
        section 1905(y)).''.
            (2) Mandatory coverage.--
                    (A) In general.--Section 2103 of such Act (42 
                U.S.C. 1397cc), is amended--
                            (i) in subsection (a), in the matter 
                        preceding paragraph (1), by striking ``and 
                        (7)'' and inserting ``(7), and (9)''; and
                            (ii) in subsection (c), by adding at the 
                        end the following:
            ``(9) End-of-life care.--The child health assistance 
        provided to a targeted low-income child shall include coverage 
        of advance care planning consultations (as defined in section 
        1905(y) and at the same payment rate as the rate that would 
        apply to such a consultation under the State plan under title 
        XIX).''.
                    (B) Conforming amendment.--Section 2102(a)(7)(B) of 
                such Act (42 U.S.C. 1397bb(a)(7)(B)) is amended by 
                striking ``section 2103(c)(5)'' and inserting 
                ``paragraphs (5) and (9) of section 2103(c)''.
    (d) Definition of Advance Directive Under Medicare, Medicaid, and 
CHIP.--
            (1) Medicare.--Section 1866(f)(3) of the Social Security 
        Act (42 U.S.C. 1395cc(f)(3)) is amended by striking ``means'' 
        and all that follows through the period and inserting ``means a 
        living will, medical directive, health care power of attorney, 
        durable power of attorney, or other written statement by a 
        competent individual that is recognized under State law and 
        indicates the individual's wishes regarding medical treatment 
        in the event of future incompetence. Such term includes an 
        advance health care directive and a health care directive 
        recognized under State law.''.
            (2) Medicaid and chip.--Section 1902(w)(4) of such Act (42 
        U.S.C. 1396a(w)(4)) is amended by striking ``means'' and all 
        that follows through the period and inserting ``means a living 
        will, medical directive, health care power of attorney, durable 
        power of attorney, or other written statement by a competent 
        individual that is recognized under State law and indicates the 
        individual's wishes regarding medical treatment in the event of 
        future incompetence. Such term includes an advance health care 
        directive and a health care directive recognized under State 
        law.''.
    (e) Effective Date.--The amendments made by this section take 
effect January 1, 2010.

                            PART II--HOSPICE

SEC. 221. ADOPTION OF MEDPAC HOSPICE PAYMENT METHODOLOGY 
              RECOMMENDATIONS.

    Section 1814(i) of the Social Security Act (42 U.S.C. 1395f(i)) is 
amended by adding at the end the following new paragraph:
            ``(6)(A) The Secretary shall conduct an evaluation of the 
        recommendations of the Medicare Payment Commission for 
        reforming the hospice care benefit under this title that are 
        contained in chapter 6 of the Commission's report entitled 
        `Report to Congress: Medicare Payment Policy (March 2009)', 
        including the impact that such recommendations if implemented 
        would have on access to care and the quality of care. In 
        conducting such evaluation, the Secretary shall take into 
        account data collected in accordance with section 263(b) of the 
        Advance Planning and Compassionate Care Act of 2009.
            ``(B) Based on the results of the examination conducted 
        under subparagraph (A), the Secretary shall make appropriate 
        refinements to the recommendations described in subparagraph 
        (A). Such refinements shall take into account--
                    ``(i) the impact on patient populations with longer 
                that average lengths of stay;
                    ``(ii) the impact on populations with shorter that 
                average lengths of stay; and
                    ``(iii) the utilization patterns of hospice 
                providers in underserved areas, including rural 
                hospices.
            ``(C) Not later than January 1, 2013, the Secretary shall 
        submit to Congress a report that contains a detailed 
        description of--
                    ``(i) the refinements determined appropriate by the 
                Secretary under subparagraph (B);
                    ``(ii) the revisions that the Secretary will 
                implement through regulation under this title pursuant 
                to subparagraph (D); and
                    ``(iii) the revisions that the Secretary determines 
                require additional legislative action by Congress.
            ``(D)(i) The Secretary shall implement the recommendations 
        described in subparagraph (A), as refined under subparagraph 
        (B).
            ``(ii) Subject to clause (iii), the implementation of such 
        recommendations shall apply to hospice care furnished on or 
        after January 1, 2014.
            ``(iii) The Secretary shall establish an appropriate 
        transition to the implementation of such recommendations.
            ``(E) For purposes of carrying out the provisions of this 
        paragraph, the Secretary shall provide for the transfer, from 
        the Federal Hospital Insurance Trust Fund under section 1817, 
        of such sums as may be necessary to the Centers for Medicare & 
        Medicaid Services Program Management Account.''.

SEC. 222. REMOVING HOSPICE INPATIENT DAYS IN SETTING PER DIEM RATES FOR 
              CRITICAL ACCESS HOSPITALS.

    Section 1814(l) of the Social Security Act (42 U.S.C. 1395f(l)), as 
amended by section 4102(b)(2) of the HITECH Act (Public Law 111-5), is 
amended by adding at the end the following new paragraph:
            ``(6) For cost reporting periods beginning on or after 
        January 1, 2011, the Secretary shall remove Medicare-certified 
        hospice inpatient days from the calculation of per diem rates 
        for inpatient critical access hospital services.''.

SEC. 223. HOSPICE PAYMENTS FOR DUAL ELIGIBLE INDIVIDUALS RESIDING IN 
              LONG-TERM CARE FACILITIES.

    (a) In General.--Section 1888 of the Social Security Act (42 U.S.C. 
1395yy) is amended by adding at the end the following new subsection:
    ``(f) Payments for Dual Eligible Individuals Residing in Long-Term 
Care Facilities.--For cost reporting periods beginning on or after 
January 1, 2011, the Secretary, acting through the Administrator of the 
Centers for Medicare & Medicaid Services, shall establish procedures 
under which payments for room and board under the State Medicaid plan 
with respect to an applicable individual are made directly to the long-
term care facility (as defined by the Secretary for purposes of title 
XIX) the individual is a resident of. For purposes of the preceding 
sentence, the term `applicable individual' means an individual who is 
entitled to or enrolled for benefits under part A or enrolled for 
benefits under part B and is eligible for medical assistance for 
hospice care under a State plan under title XIX.''.
    (b) State Plan Requirement.--
            (1) In general.--Section 1902(a) of the Social Security Act 
        (42 U.S.C. 1396a(a)) is amended--
                    (A) in paragraph (72), by striking ``and'' at the 
                end;
                    (B) in paragraph (73), by striking the period at 
                the end and inserting ``; and''; and
                    (C) by inserting after paragraph (73) the following 
                new paragraph:
            ``(74) provide that the State will make payments for room 
        and board with respect to applicable individuals in accordance 
        with section 1888(f).''.
            (2) Effective date.--
                    (A) In general.--Except as provided in subparagraph 
                (B), the amendments made by paragraph (1) take effect 
                on January 1, 2011.
                    (B) Extension of effective date for state law 
                amendment.--In the case of a State plan under title XIX 
                of the Social Security Act (42 U.S.C. 1396 et seq.) 
                which the Secretary determines requires State 
                legislation in order for the plan to meet the 
                additional requirements imposed by the amendments made 
                by paragraph (1), the State plan shall not be regarded 
                as failing to comply with the requirements of such 
                title solely on the basis of its failure to meet these 
                additional requirements before the first day of the 
                first calendar quarter beginning after the close of the 
                first regular session of the State legislature that 
                begins after the date of enactment of this Act. For 
                purposes of the previous sentence, in the case of a 
                State that has a 2-year legislative session, each year 
                of the session is considered to be a separate regular 
                session of the State legislature.

SEC. 224. DELINEATION OF RESPECTIVE CARE RESPONSIBILITIES OF HOSPICE 
              PROGRAMS AND LONG-TERM CARE FACILITIES.

    Section 1888 of the Social Security Act (42 U.S.C. 1395yy), as 
amended by section 223(a), is amended by adding at the end the 
following new subsection:
    ``(g) Delineation of Respective Care Responsibilities of Hospice 
Programs and Long-Term Care Facilities.--Not later than July 1, 2011, 
the Secretary, acting through the Administrator of the Centers for 
Medicare & Medicaid Services, shall delineate and enforce the 
respective care responsibilities of hospice programs and long-term care 
facilities (as defined by the Secretary for purposes of title XIX) with 
respect to individuals residing in such facilities who are furnished 
hospice care.''.

SEC. 225. ADOPTION OF MEDPAC HOSPICE PROGRAM ELIGIBILITY CERTIFICATION 
              AND RECERTIFICATION RECOMMENDATIONS.

    In accordance with the recommendations of the Medicare Payment 
Advisory Commission contained in the March 2009 report entitled 
``Report to Congress: Medicare Payment Policy'', section 1814(a)(7) of 
the Social Security Act (42 U.S.C. 1395f(a)(7)) is amended--
            (1) in subparagraph (B), by striking ``and'' at the end; 
        and
            (2) by adding at the end the following new subparagraph:
                    ``(D) on or after January 1, 2011--
                            ``(i) a hospice physician or advance 
                        practice nurse visits the individual to 
                        determine continued eligibility of the 
                        individual for hospice care prior to the 180th-
                        day recertification and each subsequent 
                        recertification under subparagraph (A)(ii) and 
                        attests that such visit took place (in 
                        accordance with procedures established by the 
                        Secretary, in consultation with the 
                        Administrator of the Centers for Medicare & 
                        Medicaid Services); and
                            ``(ii) any certification or recertification 
                        under subparagraph (A) includes a brief 
                        narrative describing the clinical basis for the 
                        individual's prognosis (in accordance with 
                        procedures established by the Secretary, in 
                        consultation with the Administrator of the 
                        Centers for Medicare & Medicaid Services); 
                        and''.

SEC. 226. CONCURRENT CARE FOR CHILDREN.

    (a) Permitting Medicare Hospice Beneficiaries 18 Years of Age or 
Younger To Receive Curative Care.--
            (1) In general.--Section 1812 of the Social Security Act 
        (42 U.S.C. 1395d) is amended--
                    (A) in subsection (a)(4), by inserting ``(subject 
                to the second sentence of subsection (d)(2)(A))'' after 
                ``in lieu of certain other benefits''; and
                    (B) in subsection (d)--
                            (i) in paragraph (1), by inserting `` , 
                        subject to the second sentence of paragraph 
                        (2)(A),'' after ``instead''; and
                            (ii) in paragraph (2)(A), by adding at the 
                        end the following new sentence: ``Clause 
                        (ii)(I) shall not apply to an individual who is 
                        18 years of age or younger.''
            (2) Conforming amendment.--Section 1862(a)(1)(C) of the 
        Social Security Act (42 U.S.C. 1395y(a)(1)(C)) is amended 
        inserting ``subject to the second sentence of section 
        1812(d)(2)(A),'' after ``hospice care,''.
    (b) Application to Medicaid and CHIP.--
            (1) Medicaid.--Section 1905(o)(1)(A) of the Social Security 
        Act (42 U.S.C. 1395d(o)(1)(A)) is amended by inserting 
        ``(subject, in the case of an individual who is a child, to the 
        second sentence of such section)'' after ``section 
        1812(d)(2)(A)''.
            (2) CHIP.--Section 2110(a)(23) of the Social Security Act 
        (42 U.S.C. 1397jj(a)(23)) is amended by inserting 
        ``(concurrent, in the case of an individual who is a child, 
        with care related to the treatment of the individual's 
        condition with respect to which a diagnosis of terminal illness 
        has been made)'' after ``hospice care''.
    (c) Effective Date.--The amendments made by this section shall 
apply to items and services furnished on or after January 1, 2011.

SEC. 227. MAKING HOSPICE A REQUIRED BENEFIT UNDER MEDICAID AND CHIP.

    (a) Mandatory Benefit.--
            (1) Medicaid.--
                    (A) In general.--Section 1902(a)(10)(A) of the 
                Social Security Act (42 U.S.C. 1396a(a)(10)(A)), as 
                amended by section 211(b)(1), is amended in the matter 
                preceding clause (i) by inserting ``(18),'' after 
                ``(17),''.
                    (B) Conforming amendment.--Section 1902(a)(10)(C) 
                of such Act (42 U.S.C. 1396a(a)(10)(C)) is amended--
                            (i) in clause (iii)--
                                    (I) in subclause (I), by inserting 
                                ``and hospice care'' after ``ambulatory 
                                services''; and
                                    (II) in subclause (II), by 
                                inserting ``and hospice care'' after 
                                ``delivery services''; and
                            (ii) in clause (iv), by inserting ``and 
                        (18)'' after ``(17)''.
            (2) CHIP.--Section 2103(c)(9) of such Act (42 U.S.C. 
        1397cc(c)(9)), as added by section 211(c)(2)(A), is amended by 
        inserting ``and hospice care'' before the period.
    (b) Effective Date.--The amendments made subsection (a) take effect 
on January 1, 2011.

SEC. 228. MEDICARE HOSPICE PAYMENT MODEL DEMONSTRATION PROJECTS.

    (a) Establishment.--Not later than July 1, 2012, the Secretary, 
acting through the Administrator of the Centers for Medicare & Medicaid 
Services and the Director of the Agency for Healthcare Research and 
Quality, shall conduct demonstration projects to examine ways to 
improve how the Medicare hospice care benefit predicts disease 
trajectory. Projects shall include the following models:
            (1) Models that better and more appropriately care for, and 
        transition as needed, patients in their last years of life who 
        need palliative care, but do not qualify for hospice care under 
        the Medicare hospice eligibility criteria.
            (2) Models that better and more appropriately care for 
        long-term patients who are not recertified in hospice but still 
        need palliative care.
            (3) Any other models determined appropriate by the 
        Secretary.
    (b) Waiver Authority.--The Secretary may waive compliance of such 
requirements of titles XI and XVIII of the Social Security Act as the 
Secretary determines necessary to conduct the demonstration projects 
under this section.
    (c) Reports.--The Secretary shall submit to Congress periodic 
reports on the demonstration projects conducted under this section.

SEC. 229. MEDPAC STUDIES AND REPORTS.

    (a) Study and Report Regarding an Alternative Payment Methodology 
for Hospice Care Under the Medicare Program.--
            (1) Study.--The Medicare Payment Advisory Commission (in 
        this section referred to as the ``Commission'') shall conduct a 
        study on the establishment of a reimbursement system for 
        hospice care furnished under the Medicare program that is based 
        on diagnoses. In conducting such study, the Commission shall 
        use data collected under new provider data requirements. Such 
        study shall include an analysis of the following:
                    (A) Whether such a reimbursement system better 
                meets patient needs and better corresponds with 
                provider resource expenditures than the current system.
                    (B) Whether such a reimbursement system improves 
                quality, including facilitating standardization of care 
                toward best practices and diagnoses-specific clinical 
                pathways in hospice.
                    (C) Whether such a reimbursement system could 
                address concerns about the blanket 6-month terminal 
                prognosis requirement in hospice.
                    (D) Whether such a reimbursement system is more 
                cost effective than the current system.
                    (E) Any other areas determined appropriate by the 
                Commission.
            (2) Report.--Not later than June 15, 2013, the Commission 
        shall submit to Congress a report on the study conducted under 
        subsection (a) together with recommendations for such 
        legislation and administrative action as the Commission 
        determines appropriate.
    (b) Study and Report Regarding Rural Hospice Transportation Costs 
Under the Medicare Program.--
            (1) Study.--The Commission shall conduct a study on rural 
        Medicare hospice transportation mileage to determine potential 
        Medicare reimbursement changes to account for potential higher 
        costs.
            (2) Report.--Not later than June 15, 2013, the Commission 
        shall submit to Congress a report on the study conducted under 
        subsection (a) together with recommendations for such 
        legislation and administrative action as the Commission 
        determines appropriate.
    (c) Evaluation of Reimbursement Disincentives To Elect Medicare 
Hospice Within the Medicare Skilled Nursing Facility Benefit.--
            (1) Study.--The Commission shall conduct a study to 
        determine potential Medicare reimbursement changes to remove 
        Medicare reimbursement disincentives for patients in a skilled 
        nursing facility who want to elect hospice.
            (2) Report.--Not later than June 15, 2013, the Commission 
        shall submit to Congress a report on the study conducted under 
        subsection (a) together with recommendations for such 
        legislation and administrative action as the Commission 
        determines appropriate.

SEC. 230. HHS EVALUATIONS.

    (a) Evaluation of Access to Hospice and Hospital-Based Palliative 
Care.--
            (1) Evaluation.--The Secretary, acting through the 
        Administrator of the Health Resources and Services 
        Administration, shall conduct an evaluation of geographic areas 
        and populations underserved by hospice and hospital-based 
        palliative care to identify potential barriers to access.
            (2) Report.--Not later than December 31, 2012, the 
        Secretary shall report to Congress, on the evaluation conducted 
        under subsection (a) together with recommendations for such 
        legislation and administrative action as the Secretary 
        determines appropriate to address barriers to access to hospice 
        and hospital-based palliative care.
    (b) Evaluation of Awareness and Use of Hospice Respite Care Under 
Medicare, Medicaid, and CHIP.--
            (1) Evaluation.--The Secretary, acting through the Director 
        of the Centers for Medicare and Medicaid Services, shall 
        evaluate the awareness and use of hospice respite care by 
        informal caregivers of beneficiaries under Medicare, Medicaid, 
        and CHIP.
            (2) Report.--Not later than December 31, 2010, the 
        Secretary shall report to Congress, on the evaluation conducted 
        under subsection (a) together with recommendations for such 
        legislation and administrative action as the Secretary 
        determines appropriate to increase awareness or use of hospice 
        respite care under Medicare, Medicaid, and CHIP.

                    Subtitle C--Quality Improvement

SEC. 241. PATIENT SATISFACTION SURVEYS.

    Not later than January 1, 2012, the Secretary, acting through the 
Administrator of the Centers for Medicare & Medicaid Services, shall 
establish a mechanism for--
            (1) collecting information from patients (or their health 
        care proxies or families members in the event patients are 
        unable to speak for themselves) in relevant provider settings 
        regarding their care at the end of life; and
            (2) incorporating such information in a timely manner into 
        mechanisms used by the Administrator to provide quality of care 
        information to consumers, including the Hospital Compare and 
        Nursing Home Compare websites maintained by the Administrator.

SEC. 242. DEVELOPMENT OF CORE END-OF-LIFE CARE QUALITY MEASURES ACROSS 
              EACH RELEVANT PROVIDER SETTING.

    (a) In General.--The Secretary, acting through the Administrator of 
the Agency for Healthcare Research and Quality (in this section 
referred to as the ``Administrator'') and in consultation with the 
Director of the National Institutes of Health, shall require specific 
end-of-life quality measures for each relevant provider setting, as 
identified by the Administrator, in accordance with the requirements of 
subsection (b).
    (b) Requirements.--For purposes of subsection (a), the requirements 
specified in this subsection are the following:
            (1) Selection of the specific measure or measures for an 
        identified provider setting shall be--
                    (A) based on an assessment of what is likely to 
                have the greatest positive impact on quality of end-of-
                life care in that setting; and
                    (B) made in consultation with affected providers 
                and public and private organizations, that have 
                developed such measures.
            (2) The measures may be structure-oriented, process-
        oriented, or outcome-oriented, as determined appropriate by the 
        Administrator.
            (3) The Administrator shall ensure that reporting 
        requirements related to such measures are imposed consistent 
        with other applicable laws and regulations, and in a manner 
        that takes into account existing measures, the needs of patient 
        populations, and the specific services provided.
            (4) Not later than--
                    (A) April 1, 2011, the Secretary shall disseminate 
                the reporting requirements to all affected providers; 
                and
                    (B) April 1, 2012, initial reporting relating to 
                the measures shall begin.

SEC. 243. ACCREDITATION OF HOSPITAL-BASED PALLIATIVE CARE PROGRAMS.

    (a) In General.--The Secretary, acting through the Director of the 
Agency for Healthcare Research and Quality, shall designate a public or 
private agency, entity, or organization to develop requirements, 
standards, and procedures for accreditation of hospital-based 
palliative care programs.
    (b) Reporting.--Not later than January 1, 2012, the Secretary shall 
prepare and submit a report to Congress on the proposed accreditation 
process for hospital-based palliative care programs.
    (c) Accreditation.--Not later than July 1, 2012, the Secretary 
shall--
            (1) establish and promulgate standards and procedures for 
        accreditation of hospital-based palliative care programs; and
            (2) designate an agency, entity, or organization that shall 
        be responsible for certifying such programs in accordance with 
        the standards established under paragraph (1).
    (d) Definitions.--For the purposes of this section:
            (1) The term ``hospital-based palliative care program'' 
        means a hospital-based program that is comprised of an 
        interdisciplinary team that specializes in providing palliative 
        care services and consultations in a variety of health care 
        settings, including hospitals, nursing homes, and home and 
        community-based services.
            (2) The term ``interdisciplinary team'' means a group of 
        health care professionals (consisting of, at a minimum, a 
        doctor, a nurse, and a social worker) that have received 
        specialized training in palliative care.

SEC. 244. SURVEY AND DATA REQUIREMENTS FOR ALL MEDICARE PARTICIPATING 
              HOSPICE PROGRAMS.

    (a) Hospice Surveys.--Section 1861(dd) of the Social Security Act 
(42 U.S.C. 1395x(dd)) is amended by adding at the end the following new 
paragraph:
    ``(6) In accordance with the recommendations of the Medicare 
Payment Advisory Commission contained in the March 2009 report entitled 
`Report to Congress: Medicare Payment Policy', the Secretary shall 
establish, effective July 1, 2010, the following survey requirements 
for hospice programs:
            ``(A) Any hospice program seeking initial certification 
        under this title on or after that date shall be subject to an 
        initial survey by an appropriate State or local agency, or an 
        approved accreditation agency, not later than 6 months after 
        the program first seeks such certification.
            ``(B) All hospice programs certified for participation 
        under this title shall be subject to a standard survey by an 
        appropriate State or local agency, or an approved accreditation 
        agency, at least every 3 years after initially being so 
        certified.''.
    (b) Required Hospice Resource Inputs Data.--Section 1861(dd) of the 
Social Security Act (42 U.S.C. 1395x(dd)), as amended by subsection 
(a), is amended--
            (1) in paragraph (3)--
                    (A) in subparagraph (F), by striking ``and'' at the 
                end;
                    (B) by redesignating subparagraph (G) as 
                subparagraph (H); and
                    (C) by inserting after subparagraph (F) the 
                following new subparagraph:
            ``(G) to comply with the reporting requirements under 
        paragraph (7); and''; and
            (2) by adding at the end the following new paragraph:
            ``(7)(A) In accordance with the recommendations of the 
        Medicare Payment Advisory Commission for additional data (as 
        contained in the March 2009 report entitled `Report to 
        Congress: Medicare Payment Policy'), beginning January 1, 2011, 
        a hospice program shall report to the Secretary, in such form 
        and manner, and at such intervals, as the Secretary shall 
        require, the following data with respect to each patient visit:
                    ``(i) Visit type (such as admission, routine, 
                emergency, education for family, other).
                    ``(ii) Visit length.
                    ``(iii) Professional or paraprofessional 
                disciplines involved in the visit, including nurse, 
                social worker, home health aide, physician, nurse 
                practitioner, chaplain or spiritual counselor, 
                counselor, dietician, physical therapist, occupational 
                therapist, speech language pathologist, music or art 
                therapist, and including bereavement and support 
                services provided to a family after a patient's death.
                    ``(iv) Drugs and other therapeutic interventions 
                provided.
                    ``(v) Home medical equipment and other medical 
                supplies provided.
            ``(B) In collecting the data required under subparagraph 
        (A), the Secretary shall ensure that the data are reported in a 
        manner that allows for summarized cross-tabulations of the data 
        by patients' terminal diagnoses, lengths of stay, age, sex, and 
        race.''.

       Subtitle D--Additional Reports, Research, and Evaluations

SEC. 251. NATIONAL CENTER ON PALLIATIVE AND END-OF-LIFE CARE.

    Part E of title IV of the Public Health Service Act (42 U.S.C. 287 
et seq.) is amended by adding at the end the following:

    ``Subpart 7--National Center on Palliative and End-of-Life Care

``SEC. 485J. NATIONAL CENTER ON PALLIATIVE AND END-OF-LIFE CARE.

    ``(a) Establishment.--Not later than July 1, 2011, there shall be 
established within the National Institutes of Health, a National Center 
on Palliative and End-of-Life Care (referred to in this section as the 
`Center').
    ``(b) Purpose.--The general purpose of the Center is to conduct and 
support research relating to palliative and end-of-life care 
interventions and approaches.
    ``(c) Activities.--The Center shall--
            ``(1) develop and continuously update a research agenda 
        with the goal of--
                    ``(A) providing a better biomedical understanding 
                of the end of life; and
                    ``(B) improving the quality of care and life at the 
                end of life; and
            ``(2) provide funding for peer-review-selected extra- and 
        intra-mural research that includes the evaluation of existing, 
        and the development of new, palliative and end-of-life care 
        interventions and approaches.''.

SEC. 252. NATIONAL MORTALITY FOLLOWBACK SURVEY.

    (a) In General.--Not later than December 31, 2010, and annually 
thereafter, the Secretary, acting through the Director of the Centers 
for Disease Control and Prevention, shall renew and conduct the 
National Mortality Followback Survey (referred to in this section as 
the ``Survey'') to collect data on end-of-life care.
    (b) Purpose.--The purpose of the Survey shall be to gain a better 
understanding of current end-of-life care in the United States.
    (c) Questions.--
            (1) In general.--In conducting the Survey, the Director of 
        the Centers for Disease Control and Prevention shall, at a 
        minimum, include the following questions with respect to the 
        loved one of a respondent:
                    (A) Did he or she have an advance directive, and if 
                so, when it was completed.
                    (B) Did he or she have an order for life-sustaining 
                treatment, and if so, when was it completed.
                    (C) Did he or she have a durable power of attorney, 
                and if so, when it was completed.
                    (D) Had he or she discussed his or her wishes with 
                loved ones, and if so, when.
                    (E) Had he or she discussed his or her wishes with 
                his or her physician, and if so, when.
                    (F) In the opinion of the respondent, was he or she 
                satisfied with the care he or she received in the last 
                year of life and in the last week of life.
                    (G) Was he or she cared for by hospice, and if so, 
                when.
                    (H) Was he or she cared for by palliative care 
                specialists, and if so, when.
                    (I) Did he or she receive effective pain management 
                (if needed).
                    (J) What was the experience of the main caregiver 
                (including if such caregiver was the respondent), and 
                whether he or she received sufficient support in this 
                role.
            (2) Additional questions.--Additional questions to be asked 
        during the Survey shall be determined by the Director of the 
        Centers for Disease Control and Prevention on an ongoing basis 
        with input from relevant research entities.

SEC. 253. DEMONSTRATION PROJECTS FOR USE OF TELEMEDICINE SERVICES IN 
              ADVANCE CARE PLANNING.

    (a) In General.--Not later than July 1, 2013, the Secretary shall 
establish a demonstration program to reimburse eligible entities for 
costs associated with the use of telemedicine services (including 
equipment and connection costs) to provide advance care planning 
consultations with geographically distant physicians and their 
patients.
    (b) Duration.--The demonstration project under this section shall 
be conducted for at least a 3-year period.
    (c) Definitions.--For purposes of this section:
            (1) The term ``eligible entity'' means a physician or an 
        advance practice nurse who provides services pursuant to a 
        hospital-based palliative care program (as defined in section 
        262(d)(1)).
            (2) The term ``geographically distant'' has the meaning 
        given that term by the Secretary for purposes of conducting the 
        demonstration program established under this section.
            (3) The term ``telemedicine services'' means a service or 
        consultation provided via telecommunication equipment that 
        allows an eligible entity to exchange or discuss medical 
        information with a patient or a health care professional at a 
        separate location through real-time videoconferencing, or a 
        similar format, for the purpose of providing health care 
        diagnosis and treatment.
    (d) Funding.--There are authorized to be appropriated to the 
Secretary such sums as may be necessary to carry out this section.

SEC. 254. INSPECTOR GENERAL INVESTIGATION OF FRAUD AND ABUSE.

    In accordance with the recommendations of the Medicare Payment 
Advisory Commission for additional data (as contained in the March 2009 
report entitled ``Report to Congress: Medicare Payment Policy''), the 
Secretary shall direct the Office of the Inspector General of the 
Department of Health and Human Services to investigate, not later than 
January 1, 2012, the following with respect to hospice benefit under 
Medicare, Medicaid, and CHIP:
            (1) The prevalence of financial relationships between 
        hospices and long-term care facilities, such as nursing 
        facilities and assisted living facilities, that may represent a 
        conflict of interest and influence admissions to hospice.
            (2) Differences in patterns of nursing home referrals to 
        hospice.
            (3) The appropriateness of enrollment practices for 
        hospices with unusual utilization patterns (such as high 
        frequency of very long stays, very short stays, or enrollment 
        of patients discharged from other hospices).
            (4) The appropriateness of hospice marketing materials and 
        other admissions practices and potential correlations between 
        length of stay and deficiencies in marketing or admissions 
        practices.

SEC. 255. GAO STUDY AND REPORT ON PROVIDER ADHERENCE TO ADVANCE 
              DIRECTIVES.

    Not later than January 1, 2012, the Comptroller General of the 
United States shall conduct a study of the extent to which providers 
comply with advance directives under the Medicare and Medicaid programs 
and shall submit a report to Congress on the results of such study, 
together with such recommendations for administrative or legislative 
changes as the Comptroller General determines appropriate.
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