II 

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. 

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

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

5 ‘‘Advance Planning and Compassionate Care Act of 

6 2009’’. 

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

8 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 


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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. 


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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. 

1 SEC. 2. DEFINITIONS. 

2 In this Act: 

3 (1) ADVANCE CARE PLANNING.—The term ‘‘ad4 vance care planning’’ means the process of— 

5 (A) determining an individual’s priorities, 

6 values and goals for care in the future when the 

7 individual is no longer able to express his or her 

8 wishes; 

9 (B) engaging family members, health care 

10 proxies, and health care providers in an ongoing 

11 dialogue about— 

12 (i) the individual’s wishes for care; 


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1 (ii) what the future may hold for peo2 ple with serious illnesses or injuries; 

3 (iii) how individuals, their health care 

4 proxies, and family members want their be5 liefs and preferences to guide care deci6 sions; and 

7 (iv) the steps that individuals and 

8 family members can take regarding, and 

9 the resources available to help with, fi10 nances, family matters, spiritual questions, 

11 and other issues that impact seriously ill or 

12 dying patients and their families; and 

13 (C) executing and updating advance direc14 tives and appointing a health care proxy. 

15 (2) ADVANCE DIRECTIVE.—The term ‘‘advance 

16 directive’’ means a living will, medical directive, 

17 health care power of attorney, durable power of at18 torney, or other written statement by a competent 

19 individual that is recognized under State law and in20 dicates the individual’s wishes regarding medical 

21 treatment in the event of future incompetence. Such 

22 term includes an advance health care directive and 

23 a health care directive recognized under State law. 


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1 (3) CHIP.—The term ‘‘CHIP’’ means the pro2 gram established under title XXI of the Social Secu3 rity Act (42 U.S.C. 1397aa et seq.). 

4 (4) END-OF-LIFE-CARE.—The term ‘‘end-of-life 

5 care’’ means all aspects of care of a patient with a 

6 potentially fatal condition, and includes care that is 

7 focused on specific preparations for an impending 

8 death. 

9 (5) HEALTH CARE POWER OF ATTORNEY.—The 

10 term ‘‘health care power of attorney’’ means a legal 

11 document that identifies a health care proxy or deci12 sionmaker for a patient who has the authority to act 

13 on the patient’s behalf when the patient is unable to 

14 communicate his or her wishes for medical care on 

15 matters that the patient specifies when he or she is 

16 competent. Such term includes a durable power of 

17 attorney that relates to medical care. 

18 (6) LIVING WILL.—The term ‘‘living will’’ 

19 means a legal document— 

20 (A) used to specify the type of medical 

21 care (including any type of medical treatment, 

22 including life-sustaining procedures if that per23 son becomes permanently unconscious or is oth24 erwise dying) that an individual wants provided 

25 or withheld in the event the individual cannot 


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1 speak for himself or herself and cannot express 

2 his or her wishes; and 

3 (B) that requires a physician to honor the 

4 provisions of upon receipt or to transfer the 

5 care of the individual covered by the document 

6 to another physician that will honor such provi7 sions. 

8 (7) MEDICAID.—The term ‘‘Medicaid’’ means 

9 the program established under title XIX of the So10 cial Security Act (42 U.S.C. 1396 et seq.). 

11 (8) MEDICARE.—The term ‘‘Medicare’’ means 

12 the program established under title XVIII of the So13 cial Security Act (42 U.S.C. 1395 et seq.). 

14 (9) ORDERS FOR LIFE-SUSTAINING TREAT15 MENT.—The term ‘‘orders for life-sustaining treat16 ment’’ means a process for focusing a patients’ val17 ues, goals, and preferences on current medical cir18 cumstances and to translate such into visible and 

19 portable medical orders applicable across care set20 tings, including home, long-term care, emergency 

21 medical services, and hospitals. 

22 (10) PALLIATIVE CARE.—The term ‘‘palliative 

23 care’’ means interdisciplinary care for individuals 

24 with a life-threatening illness or injury relating to 

25 pain and symptom management and psychological, 


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1 social, and spiritual needs and that seeks to improve 

2 the quality of life for the individual and the individ3 ual’s family. 

4 (11) SECRETARY.—The term ‘‘Secretary’’ 

5 means the Secretary of Health and Human Services. 

6 TITLE I—ADVANCE CARE 

7 PLANNING 

8 Subtitle A—Consumer and 

9 Provider Education 

10 PART I—CONSUMER EDUCATION 

11 Subpart A—National Initiatives 

12 SEC. 101. ADVANCE CARE PLANNING TELEPHONE HOTLINE. 

13 (a) IN GENERAL.—Not later than January 1, 2011, 

14 the Secretary, acting through the Director of the Centers 

15 for Disease Control and Prevention, shall establish and op16 erate directly, or by grant, contract, or interagency agree17 ment, a 24-hour toll-free telephone hotline to provide con18 sumer information regarding advance care planning, in19 cluding— 

20 (1) an explanation of advanced care planning 

21 and its importance; 

22 (2) issues to be considered when developing an 

23 individual’s advance care plan; 

24 (3) how to establish an advance directive; 


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1 (4) procedures to help ensure that an individ2 ual’s directives for end-of-life care are followed; 

3 (5) Federal and State-specific resources for as4 sistance with advance care planning; and 

5 (6) hospice and palliative care (including their 

6 respective purposes and services). 

7 (b) ESTABLISHMENT.—In carrying out the require8 ments under subsection (a), the Director of the Centers 

9 for Disease Control and Prevention may designate an ex10 isting 24-hour toll-free telephone hotline or, if no such 

11 service is available or appropriate, establish a new 24-hour 

12 toll-free telephone hotline. 

13 SEC. 102. ADVANCE CARE PLANNING INFORMATION CLEAR14 INGHOUSES. 

15 (a) EXPANSION OF NATIONAL CLEARINGHOUSE FOR

16 LONG-TERM CARE INFORMATION.— 

17 (1) DEVELOPMENT.—Not later than January 1, 

18 2010, the Secretary shall develop an online clearing19 house to provide comprehensive information regard20 ing advance care planning. 

21 (2) MAINTENANCE.—The advance care plan22 ning clearinghouse, which shall be clearly identifiable 

23 and available on the homepage of the Department of 

24 Health and Human Service’s National Clearinghouse 

25 for Long-Term Care Information website, shall be 


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1 maintained and publicized by the Secretary on an 

2 ongoing basis. 

3 (3) CONTENT.—The advance care planning 

4 clearinghouse shall include— 

5 (A) any relevant content contained in the 

6 national public education campaign required 

7 under section 104; 

8 (B) content addressing— 

9 (i) an explanation of advanced care 

10 planning and its importance; 

11 (ii) issues to be considered when de12 veloping an individual’s advance care plan; 

13 (iii) how to establish an advance di14 rective; 

15 (iv) procedures to help ensure that an 

16 individual’s directives for end-of-life care 

17 are followed; and 

18 (v) hospice and palliative care (includ19 ing their respective purposes and services); 

20 and 

21 (C) available Federal and State-specific re22 sources for assistance with advance care plan23 ning, including— 


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1 (i) contact information for any State 

2 public health departments that are respon3 sible for issues regarding end-of-life care; 

4 (ii) contact information for relevant 

5 legal service organizations, including those 

6 funded under the Older Americans Act of 

7 1965 (42 U.S.C. 3001 et seq.); and 

8 (iii) advance directive forms for each 

9 State; and 

10 (D) any additional information, as deter11 mined by the Secretary. 

12 (b) ESTABLISHMENT OF PEDIATRIC ADVANCE CARE

13 PLANNING CLEARINGHOUSE.— 

14 (1) DEVELOPMENT.—Not later than January 1, 

15 2011, the Secretary, in consultation with the Assist16 ant Secretary for Children and Families of the De17 partment of Health and Human Services, shall de18 velop an online clearinghouse to provide comprehen19 sive information regarding pediatric advance care 

20 planning. 

21 (2) MAINTENANCE.—The pediatric advance 

22 care planning clearinghouse, which shall be clearly 

23 identifiable on the homepage of the Administration 

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1 tained and publicized by the Secretary on an ongo2 ing basis. 

3 (3) CONTENT.—The pediatric advance care 

4 planning clearinghouse shall provide advance care 

5 planning information specific to children with life6 threatening illnesses or injuries and their families. 

7 SEC. 103. ADVANCE CARE PLANNING TOOLKIT. 

8 (a) DEVELOPMENT.—Not later than July 1, 2010, 

9 the Secretary, in consultation with the Director of the 

10 Centers for Disease Control and Prevention, shall develop 

11 an online advance care planning toolkit. 

12 (b) MAINTENANCE.—The advance care planning tool13 kit, which shall be available in English, Spanish, and any 

14 other languages that the Secretary deems appropriate, 

15 shall be maintained and publicized by the Secretary on an 

16 ongoing basis and made available on the following 

17 websites: 

18 (1) The Centers for Disease Control and Pre19 vention. 

20 (2) The Department of Health and Human 

21 Service’s National Clearinghouse for Long-Term 

22 Care Information. 

23 (3) The Administration for Children and Fami24 lies. 


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1 (c) CONTENT.—The advance care planning toolkit 

2 shall include content addressing— 

3 (1) common issues and questions regarding ad4 vance care planning, including individuals and re5 sources to contact for further inquiries; 

6 (2) advance directives and their uses, including 

7 living wills and durable powers of attorney; 

8 (3) the roles and responsibilities of a health 

9 care proxy; 

10 (4) Federal and State-specific resources to as11 sist individuals and their families with advance care 

12 planning, including— 

13 (A) the advance care planning toll-free 

14 telephone hotline established under section 101; 

15 (B) the advance care planning clearing16 houses established under section 102; 

17 (C) the advance care planning toolkit es18 tablished under this section; 

19 (D) available State legal service organiza20 tions to assist individuals with advance care 

21 planning, including those organizations that re22 ceive funding pursuant to the Older Americans 

23 Act of 1965 (42 U.S.C. 3001 et seq.); and 

24 (E) website links or addresses for State25 specific advance directive forms; and 


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1 (5) any additional information, as determined 

2 by the Secretary. 

3 SEC. 104. NATIONAL PUBLIC EDUCATION CAMPAIGN. 

4 (a) NATIONAL PUBLIC EDUCATION CAMPAIGN.— 

5 (1) IN GENERAL.—Not later than January 1, 

6 2011, the Secretary, acting through the Director of 

7 the Centers for Disease Control and Prevention, 

8 shall, directly or through grants, contracts, or inter9 agency agreements, develop and implement a na10 tional campaign to inform the public of the impor11 tance of advance care planning and of an individ12 ual’s right to direct and participate in their health 

13 care decisions. 

14 (2) CONTENT OF EDUCATIONAL CAMPAIGN.— 

15 The national public education campaign established 

16 under paragraph (1) shall— 

17 (A) employ the use of various media, in18 cluding regularly televised public service an19 nouncements; 

20 (B) provide culturally and linguistically ap21 propriate information; 

22 (C) be conducted continuously over a pe23 riod of not less than 5 years; 

24 (D) identify and promote the advance care 

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1 ment of Health and Human Service’s National 

2 Clearinghouse for Long-Term Care Information 

3 website and Administration for Children and 

4 Families website, as well as any other relevant 

5 Federal or State-specific advance care planning 

6 resources; 

7 (E) raise public awareness of the con8 sequences that may result if an individual is no 

9 longer able to express or communicate their 

10 health care decisions; 

11 (F) address the importance of individuals 

12 speaking to family members, health care prox13 ies, and health care providers as part of an on14 going dialogue regarding their health care 

15 choices; 

16 (G) address the need for individuals to ob17 tain readily available legal documents that ex18 press their health care decisions through ad19 vance directives (including living wills, comfort 

20 care orders, and durable powers of attorney for 

21 health care); 

22 (H) raise public awareness regarding the 

23 availability of hospice and palliative care; and 


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1 (I) encourage individuals to speak with 

2 their physicians about their options and inten3 tions for end-of-life care. 

4 (3) EVALUATION.— 

5 (A) IN GENERAL.—Not later than July 1, 

6 2013, the Secretary, acting through the Direc7 tor of the Centers for Disease Control and Pre8 vention, shall conduct a nationwide survey to 

9 evaluate whether the national campaign con10 ducted under this subsection has achieved its 

11 goal of changing public awareness, attitudes, 

12 and behaviors regarding advance care planning. 

13 (B) BASELINE SURVEY.—In order to 

14 evaluate the effectiveness of the national cam15 paign, the Secretary shall conduct a baseline 

16 survey prior to implementation of the campaign. 

17 (C) REPORTING REQUIREMENT.—Not later 

18 than December 31, 2013, the Secretary shall 

19 report the findings of such survey, as well as 

20 any recommendations that the Secretary deter21 mines appropriate regarding the need for con22 tinuation or legislative or administrative 

23 changes to facilitate changing public awareness, 

24 attitudes, and behaviors regarding advance care 


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1 planning, to the appropriate committees of the 

2 Congress. 

3 (b) REPEAL.—Section 4751(d) of the Omnibus 

4 Budget Reconciliation Act of 1990 (42 U.S.C. 1396a note; 

5 Public Law 101–508) is repealed. 

6 SEC. 105. UPDATE OF MEDICARE AND SOCIAL SECURITY 

7 HANDBOOKS. 

8 (a) MEDICARE & YOU HANDBOOK.— 

9 (1) IN GENERAL.—Not later than 60 days after 

10 the date of enactment of this Act, the Secretary 

11 shall update the online version of the ‘‘Planning 

12 Ahead’’ section of the Medicare & You Handbook to 

13 include— 

14 (A) an explanation of advance care plan15 ning and advance directives, including— 

16 (i) living wills; 

17 (ii) health care proxies; and 

18 (iii) after-death directives; 

19 (B) Federal and State-specific resources to 

20 assist individuals and their families with ad21 vance care planning, including— 

22 (i) the advance care planning toll-free 

23 telephone hotline established under section 

24 101; 


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1 (ii) the advance care planning clear2 inghouses established under section 102; 

3 (iii) the advance care planning toolkit 

4 established under section 103; 

5 (iv) available State legal service orga6 nizations to assist individuals with advance 

7 care planning, including those organiza8 tions that receive funding pursuant to the 

9 Older Americans Act of 1965 (42 U.S.C. 

10 3001 et seq.); and 

11 (v) website links or addresses for 

12 State-specific advance directive forms; and 

13 (C) any additional information, as deter14 mined by the Secretary. 

15 (2) UPDATE OF PAPER AND SUBSEQUENT

16 VERSIONS.—The Secretary shall include the infor17 mation described in paragraph (1) in all paper and 

18 electronic versions of the Medicare & You Handbook 

19 that are published on or after the date that is 60 

20 days after the date of enactment of this Act. 

21 (b) SOCIAL SECURITY HANDBOOK.—The Commis22 sioner of Social Security shall— 

23 (1) not later than 60 days after the date of en24 actment of this Act, update the online version of the 


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1 Social Security Handbook for beneficiaries to include 

2 the information described in subsection (a)(1); and 

3 (2) include such information in all paper and 

4 online versions of such handbook that are published 

5 on or after the date that is 60 days after the date 

6 of enactment of this Act. 

7 SEC. 106. AUTHORIZATION OF APPROPRIATIONS. 

8 There is authorized to be appropriated for the period 

9 of fiscal years 2010 through 2014— 

10 (1) $195,000,000 to the Secretary to carry out 

11 sections 101, 102, 103, 104 and 105(a); and 

12 (2) $5,000,000 to the Commissioner of Social 

13 Security to carry out section 105(b). 

14 Subpart B—State and Local Initiatives 

15 SEC. 111. FINANCIAL ASSISTANCE FOR ADVANCE CARE 

16 PLANNING. 

17 (a) LEGAL ASSISTANCE FOR ADVANCE CARE PLAN18 NING.— 

19 (1) DEFINITION OF RECIPIENT.—Section 

20 1002(6) of the Legal Services Corporation Act (42 

21 U.S.C. 2996a(6)) is amended by striking ‘‘clause (A) 

22 of’’ and inserting ‘‘subparagraph (A) or (B) of’’. 

23 (2) ADVANCE CARE PLANNING.—Section 1006 

24 of the Legal Services Corporation Act (42 U.S.C. 

25 2996e) is amended— 


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1 (A) in subsection (a)(1)— 

2 (i) by striking ‘‘title, and (B) to 

3 make’’ and inserting the following: ‘‘title; 

4 ‘‘(C) to make’’; and 

5 (ii) by inserting after subparagraph 

6 (A) the following: 

7 ‘‘(B) to provide financial assistance, and make 

8 grants and contracts, as described in subparagraph 

9 (A), on a competitive basis for the purpose of pro10 viding legal assistance in the form of advance care 

11 planning (as defined in section 3 of the Advance 

12 Planning and Compassionate Care Act of 2009, and 

13 including providing information about State-specific 

14 advance directives, as defined in that section) for eli15 gible clients under this title, including providing 

16 such planning to the family members of eligible cli17 ents and persons with power of attorney to make 

18 health care decisions for the clients; and’’; and 

19 (B) in subsection (b), by adding at the end 

20 the following: 

21 ‘‘(2) Advance care planning provided in accordance 

22 with subsection (a)(1)(B) shall not be construed to violate 

23 the Assisted Suicide Funding Restriction Act of 1997 (42 

24 U.S.C. 14401 et seq.).’’. 


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1 (3) REPORTS.—Section 1008(a) of the Legal 

2 Services Corporation Act (42 U.S.C. 2996g(a)) is 

3 amended by adding at the end the following: ‘‘The 

4 Corporation shall require such a report, on an an5 nual basis, from each grantee, contractor, or other 

6 recipient of financial assistance under section 

7 1006(a)(1)(B).’’. 

8 (4) AUTHORIZATION OF APPROPRIATIONS.— 

9 Section 1010 of the Legal Services Corporation Act 

10 (42 U.S.C. 2996i) is amended— 

11 (A) in subsection (a)— 

12 (i) by striking ‘‘(a)’’ and inserting 

13 ‘‘(a)(1)’’; 

14 (ii) in the last sentence, by striking 

15 ‘‘Appropriations for that purpose’’ and in16 serting the following: 

17 ‘‘(3) Appropriations for a purpose described in para18 graph (1) or (2)’’; and 

19 (iii) by inserting before paragraph (3) 

20 (as designated by clause (ii)) the following: 

21 ‘‘(2) There are authorized to be appropriated to carry 

22 out section 1006(a)(1)(B), $10,000,000 for each of fiscal 

23 years 2010, 2011, 2012, 2013, and 2014.’’; and 

24 (B) in subsection (d), by striking ‘‘sub25 section (a)’’ and inserting ‘‘subsection (a)(1)’’. 


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1 (5) EFFECTIVE DATE.—This subsection and the 

2 amendments made by this subsection take effect 

3 July 1, 2010. 

4 (b) STATE HEALTH INSURANCE ASSISTANCE PRO5 GRAMS.— 

6 (1) IN GENERAL.—The Secretary shall use 

7 amounts made available under paragraph (3) to 

8 award grants to States for State health insurance 

9 assistance programs receiving assistance under sec10 tion 4360 of the Omnibus Budget Reconciliation Act 

11 of 1990 to provide advance care planning services to 

12 Medicare beneficiaries, personal representatives of 

13 such beneficiaries, and the families of such bene14 ficiaries. Such services shall include information re15 garding State-specific advance directives and ways to 

16 discuss individual care wishes with health care pro17 viders. 

18 (2) REQUIREMENTS.— 

19 (A) AWARD OF GRANTS.—In making 

20 grants under this subsection for a fiscal year, 

21 the Secretary shall satisfy the following require22 ments: 

23 (i) Two-thirds of the total amount of 

24 funds available under paragraph (3) for a 

25 fiscal year shall be allocated among those 


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1 States approved for a grant under this sec2 tion that have adopted the Uniform 

3 Health-Care Decisions Act drafted by the 

4 National Conference of Commissioners on 

5 Uniform State Laws and approved and 

6 recommended for enactment by all States 

7 at the annual conference of such commis8 sioners in 1993. 

9 (ii) One-third of the total amount of 

10 funds available under paragraph (3) for a 

11 fiscal year shall be allocated among those 

12 States approved for a grant under this sec13 tion that have adopted a uniform form for 

14 orders regarding life sustaining treatment 

15 as defined in section 1861(hhh)(5) of the 

16 Social Security Act (as amended by section 

17 211 of this Act) or a comparable approach 

18 to advance care planning. 

19 (B) WORK PLAN; REPORT.—As a condition 

20 of being awarded a grant under this subsection, 

21 a State shall submit the following to the Sec22 retary: 

23 (i) An approved plan for expending 

24 grant funds. 


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1 (ii) For each fiscal year for which the 

2 State is paid grant funds under this sub3 section, an annual report regarding the use 

4 of the funds, including the number of 

5 Medicare beneficiaries served and their sat6 isfaction with the services provided. 

7 (C) LIMITATION.—No State shall be paid 

8 funds from a grant made under this subsection 

9 prior to July 1, 2010. 

10 (3) AUTHORIZATION OF APPROPRIATIONS.— 

11 There is authorized to be appropriated to the Sec12 retary to the Centers for Medicare & Medicaid Serv13 ices Program Management Account, $12,000,000 for 

14 each of fiscal years 2010 through 2014 for purposes 

15 of awarding grants to States under paragraph (1). 

16 (c) MEDICAID TRANSFORMATION GRANTS FOR AD17 VANCE CARE PLANNING.—Section 1903(z) of the Social 

18 Security Act (42 U.S.C. 1396b(z)) is amended— 

19 (1) in paragraph (2), by adding at the end the 

20 following new subparagraph: 

21 ‘‘(G) Methods for improving the effective22 ness and efficiency of medical assistance pro23 vided under this title by making available to in24 dividuals enrolled in the State plan or under a 

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1 vance care planning (as defined in section 3 of 

2 the Advance Planning and Compassionate Care 

3 Act of 2009), including at time of enrollment or 

4 renewal of enrollment in the plan or waiver, 

5 through providers, and through such other in6 novative means as the State determines appro7 priate.’’; 

8 (2) in paragraph (3), by adding at the end the 

9 following new subparagraph: 

10 ‘‘(D) WORK PLAN REQUIRED FOR AWARD

11 OF ADVANCE CARE PLANNING GRANTS.—Pay12 ment to a State under this subsection to adopt 

13 the innovative methods described in paragraph 

14 (2)(G) is conditioned on the State submitting to 

15 the Secretary an approved plan for expending 

16 the funds awarded to the State under this sub17 section.’’; and 

18 (3) in paragraph (4)— 

19 (A) in subparagraph (A)— 

20 (i) in clause (i), by striking ‘‘and’’ at 

21 the end; 

22 (ii) in clause (ii), by striking the pe23 riod at the end and inserting ‘‘; and’’; and 

24 (iii) by inserting after clause (ii), the 

25 following new clause: 


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1 ‘‘(iii) $20,000,000 for each of fiscal 

2 years 2010 through 2014.’’; and 

3 (B) by striking subparagraph (B), and in4 serting the following: 

5 ‘‘(B) ALLOCATION OF FUNDS.—The Sec6 retary shall specify a method for allocating the 

7 funds made available under this subsection 

8 among States awarded a grant for fiscal year 

9 2010, 2011, 2012, 2013, or 2014. Such method 

10 shall provide that— 

11 ‘‘(i) 100 percent of such funds for 

12 each of fiscal years 2010 through 2014 

13 shall be awarded to States that design pro14 grams to adopt the innovative methods de15 scribed in paragraph (2)(G); and 

16 ‘‘(ii) in no event shall a payment to a 

17 State awarded a grant under this sub18 section for fiscal year 2010 be made prior 

19 to July 1, 2010.’’. 

20 (d) ADVANCE CARE PLANNING COMMUNITY TRAIN21 ING GRANTS.— 

22 (1) IN GENERAL.—The Secretary shall use 

23 amounts made available under paragraph (3) to 

24 award grants to area agencies on aging (as defined 


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1 in section 102 of the Older Americans Act of 1965 

2 (42 U.S.C. 3002)). 

3 (2) REQUIREMENTS.— 

4 (A) USE OF FUNDS.—Funds awarded to 

5 an area agency on aging under this subsection 

6 shall be used to provide advance care planning 

7 education and training opportunities for local 

8 aging service providers and organizations. 

9 (B) WORK PLAN; REPORT.—As a condition 

10 of being awarded a grant under this subsection, 

11 an area agency on aging shall submit the fol12 lowing to the Secretary: 

13 (i) An approved plan for expending 

14 grant funds. 

15 (ii) For each fiscal year for which the 

16 agency is paid grant funds under this sub17 section, an annual report regarding the use 

18 of the funds, including the number of 

19 Medicare beneficiaries served and their sat20 isfaction with the services provided. 

21 (C) LIMITATION.—No area agency on 

22 aging shall be paid funds from a grant made 

23 under this subsection prior to July 1, 2010. 

24 (3) AUTHORIZATION OF APPROPRIATIONS.— 

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1 retary to the Centers for Medicare & Medicaid Serv2 ices Program Management Account, $12,000,000 for 

3 each of fiscal years 2010 through 2014 for purposes 

4 of awarding grants to area agencies on aging under 

5 paragraph (1). 

6 (e) NONDUPLICATION OF ACTIVITIES.—The Sec7 retary shall establish procedures to ensure that funds 

8 made available under grants awarded under this section 

9 or pursuant to amendments made by this section supple10 ment, not supplant, existing Federal funding, and that 

11 such funds are not used to duplicate activities carried out 

12 under such grants or under other Federally funded pro13 grams. 

14 SEC. 112. GRANTS FOR PROGRAMS FOR ORDERS REGARD15 ING LIFE SUSTAINING TREATMENT. 

16 (a) IN GENERAL.—The Secretary shall make grants 

17 to eligible entities for the purpose of— 

18 (1) establishing new programs for orders re19 garding life sustaining treatment in States or local20 ities; 

21 (2) expanding or enhancing an existing pro22 gram for orders regarding life sustaining treatment 

23 in States or localities; or 

24 (3) providing a clearinghouse of information on 

25 programs for orders for life sustaining treatment 


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1 and consultative services for the development or en2 hancement of such programs. 

3 (b) AUTHORIZED ACTIVITIES.—Activities funded 

4 through a grant under this section for an area may in5 clude— 

6 (1) developing such a program for the area that 

7 includes home care, hospice, long-term care, commu8 nity and assisted living residences, skilled nursing 

9 facilities, inpatient rehabilitation facilities, hospitals, 

10 and emergency medical services within the area; 

11 (2) securing consultative services and advice 

12 from institutions with experience in developing and 

13 managing such programs; and 

14 (3) expanding an existing program for orders 

15 regarding life sustaining treatment to serve more pa16 tients or enhance the quality of services, including 

17 educational services for patients and patients’ fami18 lies or training of health care professionals. 

19 (c) DISTRIBUTION OF FUNDS.—In funding grants 

20 under this section, the Secretary shall ensure that, of the 

21 funds appropriated to carry out this section for each fiscal 

22 year— 

23 (1) at least two-thirds are used for establishing 

24 or developing new programs for orders regarding life 

25 sustaining treatment; and 


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1 (2) one-third is used for expanding or enhanc2 ing existing programs for orders regarding life sus3 taining treatment. 

4 (d) DEFINITIONS.—In this section: 

5 (1) The term ‘‘eligible entity’’ includes— 

6 (A) an academic medical center, a medical 

7 school, a State health department, a State med8 ical association, a multi-State taskforce, a hos9 pital, or a health system capable of admin10 istering a program for orders regarding life sus11 taining treatment for a State or locality; or 

12 (B) any other health care agency or entity 

13 as the Secretary determines appropriate. 

14 (2) The term ‘‘order regarding life sustaining 

15 treatment’’ has the meaning given such term in sec16 tion 1861(hhh)(5) of the Social Security Act, as 

17 added by section 211. 

18 (3) The term ‘‘program for orders regarding 

19 life sustaining treatment’’ means, with respect to an 

20 area, a program that supports the active use of or21 ders regarding life sustaining treatment in the area. 

22 (e) AUTHORIZATION OF APPROPRIATIONS.—To carry 

23 out this section, there are authorized to be appropriated 

24 such sums as may be necessary for each of the fiscal years 

25 2009 through 2014. 


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1 PART II—PROVIDER EDUCATION 

2 SEC. 121. PUBLIC PROVIDER ADVANCE CARE PLANNING 

3 WEBSITE. 

4 (a) DEVELOPMENT.—Not later than January 1, 

5 2010, the Secretary, acting through the Administrator of 

6 the Centers for Medicare & Medicaid Services and the Di7 rector of the Agency for Healthcare Research and Quality, 

8 shall establish a website for providers under Medicare, 

9 Medicaid, the Children’s Health Insurance Program, the 

10 Indian Health Service (include contract providers) and 

11 other public health providers on each individual’s right to 

12 make decisions concerning medical care, including the 

13 right to accept or refuse medical or surgical treatment, 

14 and the existence of advance directives. 

15 (b) MAINTENANCE.—The website, shall be main16 tained and publicized by the Secretary on an ongoing 

17 basis. 

18 (c) CONTENT.—The website shall include content, 

19 tools, and resources necessary to do the following: 

20 (1) Inform providers about the advance direc21 tive requirements under the health care programs 

22 described in subsection (a) and other State and Fed23 eral laws and regulations related to advance care 

24 planning. 

25 (2) Educate providers about advance care plan26 ning quality improvement activities. 


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1 (3) Provide assistance to providers to— 

2 (A) integrate advance directives into elec3 tronic health records, including oral directives; 

4 and 

5 (B) develop and disseminate advance care 

6 planning informational materials for their pa7 tients. 

8 (4) Inform providers about advance care plan9 ning continuing education requirements and oppor10 tunities. 

11 (5) Encourage providers to discuss advance 

12 care planning with their patients of all ages. 

13 (6) Assist providers’ understanding of the con14 tinuum of end-of-life care services and supports 

15 available to patients, including palliative care and 

16 hospice. 

17 (7) Inform providers of best practices for dis18 cussing end-of-life care with dying patients and their 

19 loved ones. 

20 SEC. 122. CONTINUING EDUCATION FOR PHYSICIANS AND 

21 NURSES. 

22 (a) IN GENERAL.—Not later than January 1, 2012, 

23 the Secretary, acting through the Director of Health Re24 sources and Services Administration, shall develop, in con25 sultation with health care providers and State boards of 


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1 medicine and nursing, a curriculum for continuing edu2 cation that States may adopt for physicians and nurses 

3 on advance care planning and end-of-life care. 

4 (b) CONTENT.— 

5 (1) IN GENERAL.—The continuing education 

6 curriculum developed under subsection (a) for physi7 cians and nurses shall, at a minimum, include— 

8 (A) a description of the meaning and im9 portance of advance care planning; 

10 (B) a description of advance directives, in11 cluding living wills and durable powers of attor12 ney, and the use of such directives; 

13 (C) palliative care principles and ap14 proaches to care; and 

15 (D) the continuum of end-of-life services 

16 and supports, including palliative care and hos17 pice. 

18 (2) ADDITIONAL CONTENT FOR PHYSICIANS.— 

19 The continuing education curriculum for physicians 

20 developed under subsection (a) shall include instruc21 tion on how to conduct advance care planning with 

22 patients and their loved ones. 


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1 Subtitle B—Portability of Advance 

2 Directives; Health Information 

3 Technology 

4 SEC. 131. PORTABILITY OF ADVANCE DIRECTIVES. 

5 (a) MEDICARE.—Section 1866(f) of the Social Secu6 rity Act (42 U.S.C. 1395cc(f)) is amended— 

7 (1) in paragraph (1)— 

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

9 ‘‘and if presented by the individual, to include 

10 the content of such advance directive in a 

11 prominent part of such record’’ before the semi12 colon at the end; 

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

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

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

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

17 (D) by inserting after subparagraph (E) 

18 the following new subparagraph: 

19 ‘‘(F) to provide each individual with the oppor20 tunity to discuss issues relating to the information 

21 provided to that individual pursuant to subpara22 graph (A) with an appropriately trained profes23 sional.’’; 

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

25 and inserting ‘‘an’’; and 


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

2 paragraph: 

3 ‘‘(5)(A) An advance directive validly executed outside 

4 of the State in which such advance directive is presented 

5 by an adult individual to a provider of services, a Medicare 

6 Advantage organization, or a prepaid or eligible organiza7 tion shall be given the same effect by that provider or or8 ganization as an advance directive validly executed under 

9 the law of the State in which it is presented would be given 

10 effect. 

11 ‘‘(B)(i) The definition of an advanced directive shall 

12 also include actual knowledge of instructions made while 

13 an individual was able to express the wishes of such indi14 vidual with regard to health care. 

15 ‘‘(ii) For purposes of clause (i), the term ‘actual 

16 knowledge’ means the possession of information of an indi17 vidual’s wishes communicated to the health care provider 

18 orally or in writing by the individual, the individual’s med19 ical power of attorney representative, the individual’s 

20 health care surrogate, or other individuals resulting in the 

21 health care provider’s personal cognizance of these wishes. 

22 Other forms of imputed knowledge are not actual knowl23 edge. 

24 ‘‘(C) The provisions of this paragraph shall preempt 

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


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1 such provisions. The provisions of this paragraph shall not 

2 preempt any State law that provides for greater port3 ability, more deference to a patient’s wishes, or more lati4 tude in determining a patient’s wishes.’’. 

5 (b) MEDICAID.—Section 1902(w) of the Social Secu6 rity Act (42 U.S.C. 1396a(w)) is amended— 

7 (1) in paragraph (1)— 

8 (A) in subparagraph (B)— 

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

10 medical record’’ and inserting ‘‘in a promi11 nent part of the individual’s current med12 ical record’’; and 

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

14 the individual, to include the content of 

15 such advance directive in a prominent part 

16 of such record’’ before the semicolon at the 

17 end; 

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

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

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

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

22 (D) by inserting after subparagraph (E) 

23 the following new subparagraph: 

24 ‘‘(F) to provide each individual with the oppor25 tunity to discuss issues relating to the information 


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1 provided to that individual pursuant to subpara2 graph (A) with an appropriately trained profes3 sional.’’; 

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

5 and inserting ‘‘an’’; and 

6 (3) by adding at the end the following para7 graph: 

8 ‘‘(6)(A) An advance directive validly executed outside 

9 of the State in which such advance directive is presented 

10 by an adult individual to a provider or organization shall 

11 be given the same effect by that provider or organization 

12 as an advance directive validly executed under the law of 

13 the State in which it is presented would be given effect. 

14 ‘‘(B)(i) The definition of an advance directive shall 

15 also include actual knowledge of instructions made while 

16 an individual was able to express the wishes of such indi17 vidual with regard to health care. 

18 ‘‘(ii) For purposes of clause (i), the term ‘actual 

19 knowledge’ means the possession of information of an indi20 vidual’s wishes communicated to the health care provider 

21 orally or in writing by the individual, the individual’s med22 ical power of attorney representative, the individual’s 

23 health care surrogate, or other individuals resulting in the 

24 health care provider’s personal cognizance of these wishes. 


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1 Other forms of imputed knowledge are not actual knowl2 edge. 

3 ‘‘(C) The provisions of this paragraph shall preempt 

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

5 such provisions. The provisions of this paragraph shall not 

6 preempt any State law that provides for greater port7 ability, more deference to a patient’s wishes, or more lati8 tude in determining a patient’s wishes.’’. 

9 (c) CHIP.—Section 2107(e)(1) of the Social Security 

10 Act (42 U.S.C. 1397gg(e)(1)) is amended— 

11 (1) by redesignating subparagraphs (E) 

12 through (L) as subparagraphs (D) through (M), re13 spectively; and 

14 (2) by inserting after subparagraph (D) the fol15 lowing: 

16 ‘‘(E) Section 1902(w) (relating to advance 

17 directives).’’. 

18 (d) STUDY AND REPORT REGARDING IMPLEMENTA19 TION.— 

20 (1) STUDY.—The Secretary shall conduct a 

21 study regarding the implementation of the amend22 ments made by subsections (a) and (b). 

23 (2) REPORT.—Not later than 18 months after 

24 the date of enactment of this Act, the Secretary 

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1 ducted under paragraph (1), together with rec2 ommendations for such legislation and administra3 tive actions as the Secretary considers appropriate. 

4 (e) EFFECTIVE DATES.— 

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

6 the amendments made by subsections (a), (b), and 

7 (c) shall apply to provider agreements and contracts 

8 entered into, renewed, or extended under title XVIII 

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

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

11 U.S.C. 1396 et seq.) and State child health plans 

12 under title XXI of such Act (42 U.S.C. 1397aa et 

13 seq.), on or after such date as the Secretary speci14 fies, but in no case may such date be later than 1 

15 year after the date of enactment of this Act. 

16 (2) EXTENSION OF EFFECTIVE DATE FOR

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

18 plan under title XIX of the Social Security Act or 

19 a State child health plan under title XXI of such 

20 Act which the Secretary determines requires State 

21 legislation in order for the plan to meet the addi22 tional requirements imposed by the amendments 

23 made by subsections (b) and (c), the State plan shall 

24 not be regarded as failing to comply with the re25 quirements of such title solely on the basis of its 


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1 failure to meet these additional requirements before 

2 the first day of the first calendar quarter beginning 

3 after the close of the first regular session of the 

4 State legislature that begins after the date of enact5 ment of this Act. For purposes of the previous sen6 tence, in the case of a State that has a 2-year legis7 lative session, each year of the session is considered 

8 to be a separate regular session of the State legisla9 ture. 

10 SEC. 132. STATE ADVANCE DIRECTIVE REGISTRIES; DRIV11 ER’S LICENSE ADVANCE DIRECTIVE NOTA12 TION. 

13 Part P of title III of the Public Health Service Act 

14 (42 U.S.C. 280g) is amended— 

15 (1) by redesignating section 399R (as inserted 

16 by section 2 of Public Law 110–373) as section 

17 399S; 

18 (2) by redesignating section 399R (as inserted 

19 by section 3 of Public Law 110–374) as section 

20 399T; and 

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

22 ‘‘SEC. 399U. STATE ADVANCE DIRECTIVE REGISTRIES. 

23 ‘‘(a) STATE ADVANCE DIRECTIVE REGISTRY.—In 

24 this section, the term ‘State advance directive registry’ 

25 means a secure, electronic database that— 


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1 ‘‘(1) is available free of charge to residents of 

2 a State; and 

3 ‘‘(2) stores advance directive documents and 

4 makes such documents accessible to medical service 

5 providers in accordance with Federal and State pri6 vacy laws. 

7 ‘‘(b) GRANT PROGRAM.—Beginning on July 1, 2010, 

8 the Secretary, acting through the Director of the Centers 

9 for Disease Control and Prevention, shall award grants 

10 on a competitive basis to eligible entities to establish and 

11 operate, directly or indirectly (by competitive grant or 

12 competitive contract), State advance directive registries. 

13 ‘‘(c) ELIGIBLE ENTITIES.— 

14 ‘‘(1) IN GENERAL.—To be eligible to receive a 

15 grant under this section, an entity shall— 

16 ‘‘(A) be a State department of health; and 

17 ‘‘(B) submit to the Director an application 

18 at such time, in such manner, and containing— 

19 ‘‘(i) a plan for the establishment and 

20 operation of a State advance directive reg21 istry; and 

22 ‘‘(ii) such other information as the Di23 rector may require. 

24 ‘‘(2) NO REQUIREMENT OF NOTATION MECHA25 NISM.—The Secretary shall not require that an entiVerDate Nov 24 2008 23:09 May 26, 2009 Jkt 079200 PO 00000 Frm 00040 Fmt 6652 Sfmt 6201 E:\BILLS\S1150.IS S1150

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1 ty establish and operate a driver’s license advance 

2 directive notation mechanism for State residents 

3 under section 399V to be eligible to receive a grant 

4 under this section. 

5 ‘‘(d) ANNUAL REPORT.—For each year for which an 

6 entity receives an award under this section, such entity 

7 shall submit an annual report to the Director on the use 

8 of the funds received pursuant to such award, including 

9 the number of State residents served through the registry. 

10 ‘‘(e) AUTHORIZATION.—There is authorized to be ap11 propriated to carry out this section $20,000,000 for fiscal 

12 year 2010 and each fiscal year thereafter. 

13 ‘‘SEC. 399V. DRIVER’S LICENSE ADVANCE DIRECTIVE NOTA14 TION. 

15 ‘‘(a) IN GENERAL.—Beginning July 1, 2010, the Sec16 retary, acting through the Director of the Centers for Dis17 ease Control and Prevention, shall award grants on a com18 petitive basis to States to establish and operate a mecha19 nism for a State resident with a driver’s license to include 

20 a notice of the existence of an advance directive for such 

21 resident on such license. 

22 ‘‘(b) ELIGIBILITY.—To be eligible to receive a grant 

23 under this section, a State shall— 

24 ‘‘(1) establish and operate a State advance di25 rective registry under section 399U; and 


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1 ‘‘(2) submit to the Director an application at 

2 such time, in such manner, and containing— 

3 ‘‘(A) a plan that includes a description of 

4 how the State will— 

5 ‘‘(i) disseminate information about ad6 vance directives at the time of driver’s li7 cense application or renewal; 

8 ‘‘(ii) enable each State resident with a 

9 driver’s license to include a notice of the 

10 existence of an advance directive for such 

11 resident on such license in a manner con12 sistent with the notice on such a license in13 dicating a driver’s intent to be an organ 

14 donor; and 

15 ‘‘(iii) coordinate with the State de16 partment of health to ensure that, if a 

17 State resident has an advance directive no18 tice on his or her driver’s license, the exist19 ence of such advance directive is included 

20 in the State registry established under sec21 tion 399U; and 

22 ‘‘(B) any other information as the Director 

23 may require. 

24 ‘‘(c) ANNUAL REPORT.—For each year for which a 

25 State receives an award under this section, such State 


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1 shall submit an annual report to the Director on the use 

2 of the funds received pursuant to such award, including 

3 the number of State residents served through the mecha4 nism. 

5 ‘‘(d) AUTHORIZATION.—There is authorized to be ap6 propriated to carry out this section $50,000,000 for fiscal 

7 year 2010 and each fiscal year thereafter.’’. 

8 SEC. 133. GAO STUDY AND REPORT ON ESTABLISHMENT OF 

9 NATIONAL ADVANCE DIRECTIVE REGISTRY. 

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

11 States shall conduct a study on the feasibility of a national 

12 registry for advance directives, taking into consideration 

13 the constraints created by the privacy provisions enacted 

14 as a result of the Health Insurance Portability and Ac15 countability Act of 1996 (Public Law 104–191). 

16 (b) REPORT.—Not later than 18 months after the 

17 date of enactment of this Act, the Comptroller General 

18 of the United States shall submit to Congress a report 

19 on the study conducted under subsection (a) together with 

20 recommendations for such legislation and administrative 

21 action as the Comptroller General of the United States 

22 determines to be appropriate. 


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1 Subtitle C—National Uniform 

2 Policy on Advance Care Planning 

3 SEC. 141. STUDY AND REPORT BY THE SECRETARY RE4 GARDING THE ESTABLISHMENT AND IMPLE5 MENTATION OF A NATIONAL UNIFORM POL6 ICY ON ADVANCE DIRECTIVES. 

7 (a) STUDY.— 

8 (1) IN GENERAL.—The Secretary, acting 

9 through the Office of the Assistant Secretary for 

10 Planning and Evaluation, shall conduct a thorough 

11 study of all matters relating to the establishment 

12 and implementation of a national uniform policy on 

13 advance directives for individuals receiving items and 

14 services under titles XVIII, XIX, or XXI of the So15 cial Security Act (42 U.S.C. 1395 et seq.; 1396 et 

16 seq.; 1397aa et seq.). 

17 (2) MATTERS STUDIED.—The matters studied 

18 by the Secretary under paragraph (1) shall include 

19 issues concerning— 

20 (A) family satisfaction that a patient’s 

21 wishes, as stated in the patient’s advance direc22 tive, were carried out; 

23 (B) the portability of advance directives, 

24 including cases involving the transfer of an in25 dividual from 1 health care setting to another; 


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1 (C) immunity from civil liability and crimi2 nal responsibility for health care providers that 

3 follow the instructions in an individual’s ad4 vance directive that was validly executed in, and 

5 consistent with the laws of, the State in which 

6 it was executed; 

7 (D) conditions under which an advance di8 rective is operative; 

9 (E) revocation of an advance directive by 

10 an individual; 

11 (F) the criteria used by States for deter12 mining that an individual has a terminal condi13 tion; 

14 (G) surrogate decisionmaking regarding 

15 end-of-life care; 

16 (H) the provision of adequate palliative 

17 care (as defined in paragraph (3)), including 

18 pain management; 

19 (I) adequate and timely referrals to hos20 pice care programs; and 

21 (J) the end-of-life care needs of children 

22 and their families. 

23 (3) PALLIATIVE CARE.—For purposes of para24 graph (2)(H), the term ‘‘palliative care’’ means 

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1 threatening illness or injury relating to pain and 

2 symptom management and psychological, social, and 

3 spiritual needs and that seeks to improve the quality 

4 of life for the individual and the individual’s family. 

5 (b) REPORT TO CONGRESS.—Not later than 18 

6 months after the date of enactment of this Act, the Sec7 retary shall submit to Congress a report on the study con8 ducted under subsection (a), together with recommenda9 tions for such legislation and administrative actions as the 

10 Secretary considers appropriate. 

11 (c) CONSULTATION.—In conducting the study and 

12 developing the report under this section, the Secretary 

13 shall consult with the Uniform Law Commissioners, and 

14 other interested parties. 

15 TITLE II—COMPASSIONATE 

16 CARE 

17 Subtitle A—Workforce 

18 Development 

19 PART I—EDUCATION AND TRAINING 

20 SEC. 201. NATIONAL GERIATRIC AND PALLIATIVE CARE 

21 SERVICES CORPS. 

22 Section 331 of the Public Health Service Act (42 

23 U.S.C. 254d) is amended— 

24 (1) by redesignating subsection (j) as sub25 section (k); and 


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1 (2) by inserting after subsection (i), the fol2 lowing: 

3 ‘‘(j) NATIONAL GERIATRIC AND PALLIATIVE CARE

4 SERVICES CORPS.— 

5 ‘‘(1) ESTABLISHMENT.—Not later than Janu6 ary 1, 2012, the Secretary shall establish within the 

7 National Health Service Corps a National Geriatric 

8 and Palliative Care Services Corps (referred to in 

9 this subsection as the ‘Corps’) which shall consist 

10 of— 

11 ‘‘(A) such officers of the Regular and Re12 serve Corps of the Service as the Secretary may 

13 designate; 

14 ‘‘(B) such civilian employees of the United 

15 States as the Secretary may appoint; and 

16 ‘‘(C) such other individuals who are not 

17 employees of the United States. 

18 ‘‘(2) DUTIES.—The Corps shall be utilized by 

19 the Secretary to provide geriatric and palliative care 

20 services within health professional shortage areas. 

21 ‘‘(3) APPLICATION OF PROVISIONS.—The loan22 forgiveness, scholarship, and direct financial incen23 tives programs provided for under this section shall 

24 apply to physicians, nurses, and other health profes25 sionals (as identified by the Secretary) with respect 


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1 to the training necessary to enable such individuals 

2 to become geriatric or palliative care specialists and 

3 provide geriatric and palliative care services in 

4 health professional shortage areas. 

5 ‘‘(4) REPORT.—Not later than 6 months prior 

6 to the date on which the Secretary establishes the 

7 Corps under paragraph (1), the Secretary shall sub8 mit to Congress a report concerning the organization 

9 of the Corps, the application process for membership 

10 in the Corps, and the funding necessary for the 

11 Corps (targeted by profession and by specializa12 tion).’’. 

13 SEC. 202. EXEMPTION OF PALLIATIVE MEDICINE FELLOW14 SHIP TRAINING FROM MEDICARE GRADUATE 

15 MEDICAL EDUCATION CAPS. 

16 (a) DIRECT GRADUATE MEDICAL EDUCATION.—Sec17 tion 1886(h)(4)(F) of the Social Security Act (42 U.S.C. 

18 1395ww(h)(4)(F)) is amended— 

19 (1) in clause (i), by inserting ‘‘clause (iii) and’’ 

20 after ‘‘subject to’’; and 

21 (2) by adding at the end the following new 

22 clause: 

23 ‘‘(iii) INCREASE ALLOWED FOR PAL24 LIATIVE MEDICINE FELLOWSHIP TRAIN25 ING.—For cost reporting periods beginning 


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1 on or after January 1, 2011, in applying 

2 clause (i), there shall not be taken into ac3 count full-time equivalent residents in the 

4 field of allopathic or osteopathic medicine 

5 who are in palliative medicine fellowship 

6 training that is approved by the Accredita7 tion Council for Graduate Medical Edu8 cation.’’. 

9 (b) INDIRECT MEDICAL EDUCATION.—Section 

10 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 

11 1395ww(d)(5)(B)) is amended by adding at the end the 

12 following new clause: 

13 ‘‘(x) Clause (iii) of subsection (h)(4)(F) shall 

14 apply to clause (v) in the same manner and for the 

15 same period as such clause (iii) applies to clause (i) 

16 of such subsection.’’. 

17 SEC. 203. MEDICAL SCHOOL CURRICULA. 

18 (a) IN GENERAL.—The Secretary, in consultation 

19 with the Association of American Medical Colleges, shall 

20 establish guidelines for the imposition by medical schools 

21 of a minimum amount of end-of-life training as a require22 ment for obtaining a Doctor of Medicine degree in the field 

23 of allopathic or osteopathic medicine. 

24 (b) TRAINING.—Under the guidelines established 

25 under subsection (a), minimum training shall include— 


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1 (1) training in how to discuss and help patients 

2 and their loved ones with advance care planning; 

3 (2) with respect to students and trainees who 

4 will work with children, specialized pediatric train5 ing; 

6 (3) training in the continuum of end-of-life 

7 services and supports, including palliative care and 

8 hospice; 

9 (4) training in how to discuss end-of-life care 

10 with dying patients and their loved ones; and 

11 (5) medical and legal issues training. 

12 (c) DISTRIBUTION.—Not later than January 1, 2011, 

13 the Secretary shall disseminate the guidelines established 

14 under subsection (a) to medical schools. 

15 (d) COMPLIANCE.—Effective beginning not later than 

16 July 1, 2012, a medical school that is receiving Federal 

17 assistance shall be required to implement the guidelines 

18 established under subsection (a). A medical school that the 

19 Secretary determines is not implementing such guidelines 

20 shall not be eligible for Federal assistance. 


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1 Subtitle B—Coverage Under 

2 Medicare, Medicaid, and CHIP 

3 PART I—COVERAGE OF ADVANCE CARE 

4 PLANNING 

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

6 (a) MEDICARE.— 

7 (1) IN GENERAL.—Section 1861 of the Social 

8 Security Act (42 U.S.C. 1395x) is amended— 

9 (A) in subsection (s)(2)— 

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

11 subparagraph (DD); 

12 (ii) by adding ‘‘and’’ at the end of 

13 subparagraph (EE); and 

14 (iii) by adding at the end the fol15 lowing new subparagraph: 

16 ‘‘(FF) advance care planning consultation 

17 (as defined in subsection (hhh)(1));’’; and 

18 (B) by adding at the end the following new 

19 subsection: 

20 ‘‘Advance Care Planning Consultation 

21 ‘‘(hhh)(1) Subject to paragraphs (3) and (4), the 

22 term ‘advance care planning consultation’ means a con23 sultation between the individual and a practitioner de24 scribed in paragraph (2) regarding advance care planning, 

25 if, subject to subparagraphs (A) and (B) of paragraph (3), 


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1 the individual involved has not had such a consultation 

2 within the last 5 years. Such consultation shall include the 

3 following: 

4 ‘‘(A) An explanation by the practitioner of ad5 vance care planning, including key questions and 

6 considerations, important steps, and suggested peo7 ple to talk to. 

8 ‘‘(B) An explanation by the practitioner of ad9 vance directives, including living wills and durable 

10 powers of attorney, and their uses. 

11 ‘‘(C) An explanation by the practitioner of the 

12 role and responsibilities of a health care proxy. 

13 ‘‘(D) The provision by the practitioner of a list 

14 of national and State-specific resources to assist con15 sumers and their families with advance care plan16 ning, including the national toll-free hotline, the ad17 vance care planning clearinghouses, and State legal 

18 service organizations (including those funded 

19 through the Older Americans Act). 

20 ‘‘(E) An explanation by the practitioner of the 

21 continuum of end-of-life services and supports avail22 able, including palliative care and hospice, and bene23 fits for such services and supports that are available 

24 under this title. 


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1 ‘‘(F)(i) Subject to clause (ii), an explanation of 

2 orders regarding life sustaining treatment or similar 

3 orders, which shall include— 

4 ‘‘(I) the reasons why the development of 

5 such an order is beneficial to the individual and 

6 the individual’s family and the reasons why 

7 such an order should be updated periodically as 

8 the health of the individual changes; 

9 ‘‘(II) the information needed for an indi10 vidual or legal surrogate to make informed deci11 sions regarding the completion of such an 

12 order; and 

13 ‘‘(III) the identification of resources that 

14 an individual may use to determine the require15 ments of the State in which such individual re16 sides so that the treatment wishes of that indi17 vidual will be carried out if the individual is un18 able to communicate those wishes, including re19 quirements regarding the designation of a sur20 rogate decisionmaker (also known as a health 

21 care proxy). 

22 ‘‘(ii) The Secretary may limit the requirement 

23 for explanations under clause (i) to consultations 

24 furnished in States, localities, or other geographic 


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1 areas in which orders described in such clause have 

2 been widely adopted. 

3 ‘‘(2) A practitioner described in this paragraph is— 

4 ‘‘(A) a physician (as defined in subsection 

5 (r)(1)); and 

6 ‘‘(B) a nurse practitioner or physician’s assist7 ant who has the authority under State law to sign 

8 orders for life sustaining treatments. 

9 ‘‘(3)(A) An initial preventive physical examination 

10 under subsection (ww), including any related discussion 

11 during such examination, shall not be considered an ad12 vance care planning consultation for purposes of applying 

13 the 5-year limitation under paragraph (1). 

14 ‘‘(B) An advance care planning consultation with re15 spect to an individual shall be conducted more frequently 

16 than provided under paragraph (1) if there is a significant 

17 change in the health condition of the individual, including 

18 diagnosis of a chronic, progressive, life-limiting disease, a 

19 life-threatening or terminal diagnosis or life-threatening 

20 injury, or upon admission to a skilled nursing facility, a 

21 long-term care facility (as defined by the Secretary), or 

22 a hospice program. 

23 ‘‘(4) A consultation under this subsection may in24 clude the formulation of an order regarding life sustaining 

25 treatment or a similar order. 


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1 ‘‘(5)(A) For purposes of this section, the term ‘order 

2 regarding life sustaining treatment’ means, with respect 

3 to an individual, an actionable medical order relating to 

4 the treatment of that individual that— 

5 ‘‘(i) is signed and dated by a physician (as de6 fined in subsection (r)(1)) or another health care 

7 professional (as specified by the Secretary and who 

8 is acting within the scope of the professional’s au9 thority under State law in signing such an order) 

10 and is in a form that permits it to stay with the pa11 tient and be followed by health care professionals 

12 and providers across the continuum of care, includ13 ing home care, hospice, long-term care, community 

14 and assisted living residences, skilled nursing facili15 ties, inpatient rehabilitation facilities, hospitals, and 

16 emergency medical services; 

17 ‘‘(ii) effectively communicates the individual’s 

18 preferences regarding life sustaining treatment, in19 cluding an indication of the treatment and care de20 sired by the individual; 

21 ‘‘(iii) is uniquely identifiable and standardized 

22 within a given locality, region, or State (as identified 

23 by the Secretary); 

24 ‘‘(iv) is portable across care settings; and 


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1 ‘‘(v) may incorporate any advance directive (as 

2 defined in section 1866(f)(3)) if executed by the in3 dividual. 

4 ‘‘(B) The level of treatment indicated under subpara5 graph (A)(ii) may range from an indication for full treat6 ment to an indication to limit some or all or specified 

7 interventions. Such indicated levels of treatment may in8 clude indications respecting, among other items— 

9 ‘‘(i) the intensity of medical intervention if the 

10 patient is pulseless, apneic, or has serious cardiac or 

11 pulmonary problems; 

12 ‘‘(ii) the individual’s desire regarding transfer 

13 to a hospital or remaining at the current care set14 ting; 

15 ‘‘(iii) the use of antibiotics; and 

16 ‘‘(iv) the use of artificially administered nutri17 tion and hydration.’’. 

18 (2) PAYMENT.—Section 1848(j)(3) of the So19 cial Security Act (42 U.S.C. 1395w–4(j)(3)) is 

20 amended by inserting ‘‘(2)(FF),’’ after ‘‘(2)(EE),’’. 

21 (3) FREQUENCY LIMITATION.—Section 1862(a) 

22 of the Social Security Act (42 U.S.C. 1395y(a)(1)) 

23 is amended— 

24 (A) in paragraph (1)— 


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1 (i) in subparagraph (N), by striking 

2 ‘‘and’’ at the end; 

3 (ii) in subparagraph (O) by striking 

4 the semicolon at the end and inserting ‘‘, 

5 and’’; and 

6 (iii) by adding at the end the fol7 lowing new subparagraph: 

8 ‘‘(P) in the case of advance care planning con9 sultations (as defined in section 1861(hhh)(1)), 

10 which are performed more frequently than is covered 

11 under such section;’’; and 

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

13 and inserting ‘‘(K), or (P)’’. 

14 (4) EFFECTIVE DATE.—The amendments made 

15 by this subsection shall apply to consultations fur16 nished on or after January 1, 2011. 

17 (b) MEDICAID.— 

18 (1) MANDATORY BENEFIT.—Section 

19 1902(a)(10)(A) of the Social Security Act (42 

20 U.S.C. 1396a(a)(10)(A)) is amended in the matter 

21 preceding clause (i) by striking ‘‘and (21)’’ and in22 serting ‘‘, (21), and (28)’’. 

23 (2) MEDICAL ASSISTANCE.—Section 1905 of 

24 such Act (42 U.S.C. 1396d) is amended— 

25 (A) in subsection (a)— 


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1 (i) in paragraph (27), by striking 

2 ‘‘and’’ at the end; 

3 (ii) by redesignating paragraph (28) 

4 as paragraph (29); and 

5 (iii) by inserting after paragraph (27) 

6 the following new paragraph: 

7 ‘‘(28) advance care planning consultations (as 

8 defined in subsection (y));’’; and 

9 (B) by adding at the end the following: 

10 ‘‘(y)(1) For purposes of subsection (a)(28), the term 

11 ‘advance care planning consultation’ means a consultation 

12 between the individual and a practitioner described in 

13 paragraph (2) regarding advance care planning, if, subject 

14 to paragraph (3), the individual involved has not had such 

15 a consultation within the last 5 years. Such consultation 

16 shall include the following: 

17 ‘‘(A) An explanation by the practitioner of ad18 vance care planning, including key questions and 

19 considerations, important steps, and suggested peo20 ple to talk to. 

21 ‘‘(B) An explanation by the practitioner of ad22 vance directives, including living wills and durable 

23 powers of attorney, and their uses. 

24 ‘‘(C) An explanation by the practitioner of the 

25 role and responsibilities of a health care proxy. 


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1 ‘‘(D) The provision by the practitioner of a list 

2 of national and State-specific resources to assist con3 sumers and their families with advance care plan4 ning, including the national toll-free hotline, the ad5 vance care planning clearinghouses, and State legal 

6 service organizations (including those funded 

7 through the Older Americans Act). 

8 ‘‘(E) An explanation by the practitioner of the 

9 continuum of end-of-life services and supports avail10 able, including palliative care and hospice, and bene11 fits for such services and supports that are available 

12 under this title. 

13 ‘‘(F)(i) Subject to clause (ii), an explanation of 

14 orders for life sustaining treatments or similar or15 ders, which shall include— 

16 ‘‘(I) the reasons why the development of 

17 such an order is beneficial to the individual and 

18 the individual’s family and the reasons why 

19 such an order should be updated periodically as 

20 the health of the individual changes; 

21 ‘‘(II) the information needed for an indi22 vidual or legal surrogate to make informed deci23 sions regarding the completion of such an 

24 order; and 


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1 ‘‘(III) the identification of resources that 

2 an individual may use to determine the require3 ments of the State in which such individual re4 sides so that the treatment wishes of that indi5 vidual will be carried out if the individual is un6 able to communicate those wishes, including re7 quirements regarding the designation of a sur8 rogate decisionmaker (also known as a health 

9 care proxy). 

10 ‘‘(ii) The Secretary may limit the requirement 

11 for explanations under clause (i) to consultations 

12 furnished in States, localities, or other geographic 

13 areas in which orders described in such clause have 

14 been widely adopted. 

15 ‘‘(2) A practitioner described in this paragraph is— 

16 ‘‘(A) a physician (as defined in section 

17 1861(r)(1)); and 

18 ‘‘(B) a nurse practitioner or physician’s assist19 ant who has the authority under State law to sign 

20 orders for life sustaining treatments. 

21 ‘‘(3) An advance care planning consultation with re22 spect to an individual shall be conducted more frequently 

23 than provided under paragraph (1) if there is a significant 

24 change in the health condition of the individual including 

25 diagnosis of a chronic, progressive, life-limiting disease, a 


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1 life-threatening or terminal diagnosis or life-threatening 

2 injury, or upon admission to a nursing facility, a long3 term care facility (as defined by the Secretary), or a hos4 pice program. 

5 ‘‘(4) A consultation under this subsection may in6 clude the formulation of an order regarding life sustaining 

7 treatment or a similar order. 

8 ‘‘(5) For purposes of this subsection, the term ‘orders 

9 regarding life sustaining treatment’ has the meaning given 

10 that term in section 1861(hhh)(5).’’. 

11 (c) CHIP.— 

12 (1) CHILD HEALTH ASSISTANCE.—Section 

13 2110(a) of the Social Security Act (42 U.S.C. 

14 1397jj) is amended— 

15 (A) by redesignating paragraph (28) as 

16 paragraph (29); and 

17 (B) by inserting after paragraph (27), the 

18 following: 

19 ‘‘(28) Advance care planning consultations (as 

20 defined in section 1905(y)).’’. 

21 (2) MANDATORY COVERAGE.— 

22 (A) IN GENERAL.—Section 2103 of such 

23 Act (42 U.S.C. 1397cc), is amended— 


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1 (i) in subsection (a), in the matter 

2 preceding paragraph (1), by striking ‘‘and 

3 (7)’’ and inserting ‘‘(7), and (9)’’; and 

4 (ii) in subsection (c), by adding at the 

5 end the following: 

6 ‘‘(9) END-OF-LIFE CARE.—The child health as7 sistance provided to a targeted low-income child 

8 shall include coverage of advance care planning con9 sultations (as defined in section 1905(y) and at the 

10 same payment rate as the rate that would apply to 

11 such a consultation under the State plan under title 

12 XIX).’’. 

13 (B) CONFORMING AMENDMENT.—Section 

14 2102(a)(7)(B) of such Act (42 U.S.C. 

15 1397bb(a)(7)(B)) is amended by striking ‘‘sec16 tion 2103(c)(5)’’ and inserting ‘‘paragraphs (5) 

17 and (9) of section 2103(c)’’. 

18 (d) DEFINITION OF ADVANCE DIRECTIVE UNDER

19 MEDICARE, MEDICAID, AND CHIP.— 

20 (1) MEDICARE.—Section 1866(f)(3) of the So21 cial Security Act (42 U.S.C. 1395cc(f)(3)) is amend22 ed by striking ‘‘means’’ and all that follows through 

23 the period and inserting ‘‘means a living will, med24 ical directive, health care power of attorney, durable 

25 power of attorney, or other written statement by a 


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1 competent individual that is recognized under State 

2 law and indicates the individual’s wishes regarding 

3 medical treatment in the event of future incom4 petence. Such term includes an advance health care 

5 directive and a health care directive recognized 

6 under State law.’’. 

7 (2) MEDICAID AND CHIP.—Section 1902(w)(4) 

8 of such Act (42 U.S.C. 1396a(w)(4)) is amended by 

9 striking ‘‘means’’ and all that follows through the 

10 period and inserting ‘‘means a living will, medical di11 rective, health care power of attorney, durable power 

12 of attorney, or other written statement by a com13 petent individual that is recognized under State law 

14 and indicates the individual’s wishes regarding med15 ical treatment in the event of future incompetence. 

16 Such term includes an advance health care directive 

17 and a health care directive recognized under State 

18 law.’’. 

19 (e) EFFECTIVE DATE.—The amendments made by 

20 this section take effect January 1, 2010. 


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1 PART II—HOSPICE 

2 SEC. 221. ADOPTION OF MEDPAC HOSPICE PAYMENT METH3 ODOLOGY RECOMMENDATIONS. 

4 Section 1814(i) of the Social Security Act (42 U.S.C. 

5 1395f(i)) is amended by adding at the end the following 

6 new paragraph: 

7 ‘‘(6)(A) The Secretary shall conduct an evalua8 tion of the recommendations of the Medicare Pay9 ment Commission for reforming the hospice care 

10 benefit under this title that are contained in chapter 

11 6 of the Commission’s report entitled ‘Report to 

12 Congress: Medicare Payment Policy (March 2009)’, 

13 including the impact that such recommendations if 

14 implemented would have on access to care and the 

15 quality of care. In conducting such evaluation, the 

16 Secretary shall take into account data collected in 

17 accordance with section 263(b) of the Advance Plan18 ning and Compassionate Care Act of 2009. 

19 ‘‘(B) Based on the results of the examination 

20 conducted under subparagraph (A), the Secretary 

21 shall make appropriate refinements to the rec22 ommendations described in subparagraph (A). Such 

23 refinements shall take into account— 

24 ‘‘(i) the impact on patient populations with 

25 longer that average lengths of stay; 


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1 ‘‘(ii) the impact on populations with short2 er that average lengths of stay; and 

3 ‘‘(iii) the utilization patterns of hospice 

4 providers in underserved areas, including rural 

5 hospices. 

6 ‘‘(C) Not later than January 1, 2013, the Sec7 retary shall submit to Congress a report that con8 tains a detailed description of— 

9 ‘‘(i) the refinements determined appro10 priate by the Secretary under subparagraph 

11 (B); 

12 ‘‘(ii) the revisions that the Secretary will 

13 implement through regulation under this title 

14 pursuant to subparagraph (D); and 

15 ‘‘(iii) the revisions that the Secretary de16 termines require additional legislative action by 

17 Congress. 

18 ‘‘(D)(i) The Secretary shall implement the rec19 ommendations described in subparagraph (A), as re20 fined under subparagraph (B). 

21 ‘‘(ii) Subject to clause (iii), the implementation 

22 of such recommendations shall apply to hospice care 

23 furnished on or after January 1, 2014. 


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1 ‘‘(iii) The Secretary shall establish an appro2 priate transition to the implementation of such rec3 ommendations. 

4 ‘‘(E) For purposes of carrying out the provi5 sions of this paragraph, the Secretary shall provide 

6 for the transfer, from the Federal Hospital Insur7 ance Trust Fund under section 1817, of such sums 

8 as may be necessary to the Centers for Medicare & 

9 Medicaid Services Program Management Account.’’. 

10 SEC. 222. REMOVING HOSPICE INPATIENT DAYS IN SET11 TING PER DIEM RATES FOR CRITICAL AC12 CESS HOSPITALS. 

13 Section 1814(l) of the Social Security Act (42 U.S.C. 

14 1395f(l)), as amended by section 4102(b)(2) of the 

15 HITECH Act (Public Law 111–5), is amended by adding 

16 at the end the following new paragraph: 

17 ‘‘(6) For cost reporting periods beginning on or 

18 after January 1, 2011, the Secretary shall remove 

19 Medicare-certified hospice inpatient days from the 

20 calculation of per diem rates for inpatient critical ac21 cess hospital services.’’. 


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1 SEC. 223. HOSPICE PAYMENTS FOR DUAL ELIGIBLE INDI2 VIDUALS RESIDING IN LONG-TERM CARE FA3 CILITIES. 

4 (a) IN GENERAL.—Section 1888 of the Social Secu5 rity Act (42 U.S.C. 1395yy) is amended by adding at the 

6 end the following new subsection: 

7 ‘‘(f) PAYMENTS FOR DUAL ELIGIBLE INDIVIDUALS

8 RESIDING IN LONG-TERM CARE FACILITIES.—For cost 

9 reporting periods beginning on or after January 1, 2011, 

10 the Secretary, acting through the Administrator of the 

11 Centers for Medicare & Medicaid Services, shall establish 

12 procedures under which payments for room and board 

13 under the State Medicaid plan with respect to an applica14 ble individual are made directly to the long-term care facil15 ity (as defined by the Secretary for purposes of title XIX) 

16 the individual is a resident of. For purposes of the pre17 ceding sentence, the term ‘applicable individual’ means an 

18 individual who is entitled to or enrolled for benefits under 

19 part A or enrolled for benefits under part B and is eligible 

20 for medical assistance for hospice care under a State plan 

21 under title XIX.’’. 

22 (b) STATE PLAN REQUIREMENT.— 

23 (1) IN GENERAL.—Section 1902(a) of the So24 cial Security Act (42 U.S.C. 1396a(a)) is amend25 ed— 


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1 (A) in paragraph (72), by striking ‘‘and’’ 

2 at the end; 

3 (B) in paragraph (73), by striking the pe4 riod at the end and inserting ‘‘; and’’; and 

5 (C) by inserting after paragraph (73) the 

6 following new paragraph: 

7 ‘‘(74) provide that the State will make pay8 ments for room and board with respect to applicable 

9 individuals in accordance with section 1888(f).’’. 

10 (2) EFFECTIVE DATE.— 

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

12 subparagraph (B), the amendments made by 

13 paragraph (1) take effect on January 1, 2011. 

14 (B) EXTENSION OF EFFECTIVE DATE FOR

15 STATE LAW AMENDMENT.—In the case of a 

16 State plan under title XIX of the Social Secu17 rity Act (42 U.S.C. 1396 et seq.) which the 

18 Secretary determines requires State legislation 

19 in order for the plan to meet the additional re20 quirements imposed by the amendments made 

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

22 regarded as failing to comply with the require23 ments of such title solely on the basis of its fail24 ure to meet these additional requirements be25 fore the first day of the first calendar quarter 


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1 beginning after the close of the first regular 

2 session of the State legislature that begins after 

3 the date of enactment of this Act. For purposes 

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

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

6 of the session is considered to be a separate 

7 regular session of the State legislature. 

8 SEC. 224. DELINEATION OF RESPECTIVE CARE RESPON9 SIBILITIES OF HOSPICE PROGRAMS AND 

10 LONG-TERM CARE FACILITIES. 

11 Section 1888 of the Social Security Act (42 U.S.C. 

12 1395yy), as amended by section 223(a), is amended by 

13 adding at the end the following new subsection: 

14 ‘‘(g) DELINEATION OF RESPECTIVE CARE RESPON15 SIBILITIES OF HOSPICE PROGRAMS AND LONG-TERM

16 CARE FACILITIES.—Not later than July 1, 2011, the Sec17 retary, acting through the Administrator of the Centers 

18 for Medicare & Medicaid Services, shall delineate and en19 force the respective care responsibilities of hospice pro20 grams and long-term care facilities (as defined by the Sec21 retary for purposes of title XIX) with respect to individ22 uals residing in such facilities who are furnished hospice 

23 care.’’. 


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1 SEC. 225. ADOPTION OF MEDPAC HOSPICE PROGRAM ELI2 GIBILITY CERTIFICATION AND RECERTIFI3 CATION RECOMMENDATIONS. 

4 In accordance with the recommendations of the Medi5 care Payment Advisory Commission contained in the 

6 March 2009 report entitled ‘‘Report to Congress: Medi7 care Payment Policy’’, section 1814(a)(7) of the Social Se8 curity Act (42 U.S.C. 1395f(a)(7)) is amended— 

9 (1) in subparagraph (B), by striking ‘‘and’’ at 

10 the end; and 

11 (2) by adding at the end the following new sub12 paragraph: 

13 ‘‘(D) on or after January 1, 2011— 

14 ‘‘(i) a hospice physician or advance 

15 practice nurse visits the individual to de16 termine continued eligibility of the indi17 vidual for hospice care prior to the 180th18 day recertification and each subsequent re19 certification under subparagraph (A)(ii) 

20 and attests that such visit took place (in 

21 accordance with procedures established by 

22 the Secretary, in consultation with the Ad23 ministrator of the Centers for Medicare & 

24 Medicaid Services); and 

25 ‘‘(ii) any certification or recertification 

26 under subparagraph (A) includes a brief 


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1 narrative describing the clinical basis for 

2 the individual’s prognosis (in accordance 

3 with procedures established by the Sec4 retary, in consultation with the Adminis5 trator of the Centers for Medicare & Med6 icaid Services); and’’. 

7 SEC. 226. CONCURRENT CARE FOR CHILDREN. 

8 (a) PERMITTING MEDICARE HOSPICE BENE9 FICIARIES 18 YEARS OF AGE OR YOUNGER TO RECEIVE

10 CURATIVE CARE.— 

11 (1) IN GENERAL.—Section 1812 of the Social 

12 Security Act (42 U.S.C. 1395d) is amended— 

13 (A) in subsection (a)(4), by inserting 

14 ‘‘(subject to the second sentence of subsection 

15 (d)(2)(A))’’ after ‘‘in lieu of certain other bene16 fits’’; and 

17 (B) in subsection (d)— 

18 (i) in paragraph (1), by inserting ‘‘ , 

19 subject to the second sentence of para20 graph (2)(A),’’ after ‘‘instead’’; and 

21 (ii) in paragraph (2)(A), by adding at 

22 the end the following new sentence: 

23 ‘‘Clause (ii)(I) shall not apply to an indi24 vidual who is 18 years of age or younger.’’ 


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1 (2) CONFORMING AMENDMENT.—Section 

2 1862(a)(1)(C) of the Social Security Act (42 U.S.C. 

3 1395y(a)(1)(C)) is amended inserting ‘‘subject to 

4 the second sentence of section 1812(d)(2)(A),’’ after 

5 ‘‘hospice care,’’. 

6 (b) APPLICATION TO MEDICAID AND CHIP.— 

7 (1) MEDICAID.—Section 1905(o)(1)(A) of the 

8 Social Security Act (42 U.S.C. 1395d(o)(1)(A)) is 

9 amended by inserting ‘‘(subject, in the case of an in10 dividual who is a child, to the second sentence of 

11 such section)’’ after ‘‘section 1812(d)(2)(A)’’. 

12 (2) CHIP.—Section 2110(a)(23) of the Social 

13 Security Act (42 U.S.C. 1397jj(a)(23)) is amended 

14 by inserting ‘‘(concurrent, in the case of an indi15 vidual who is a child, with care related to the treat16 ment of the individual’s condition with respect to 

17 which a diagnosis of terminal illness has been 

18 made)’’ after ‘‘hospice care’’. 

19 (c) EFFECTIVE DATE.—The amendments made by 

20 this section shall apply to items and services furnished on 

21 or after January 1, 2011. 

22 SEC. 227. MAKING HOSPICE A REQUIRED BENEFIT UNDER 

23 MEDICAID AND CHIP. 

24 (a) MANDATORY BENEFIT.— 

25 (1) MEDICAID.— 


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1 (A) IN GENERAL.—Section 1902(a)(10)(A) 

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

3 1396a(a)(10)(A)), as amended by section 

4 211(b)(1), is amended in the matter preceding 

5 clause (i) by inserting ‘‘(18),’’ after ‘‘(17),’’. 

6 (B) CONFORMING AMENDMENT.—Section 

7 1902(a)(10)(C) of such Act (42 U.S.C. 

8 1396a(a)(10)(C)) is amended— 

9 (i) in clause (iii)— 

10 (I) in subclause (I), by inserting 

11 ‘‘and hospice care’’ after ‘‘ambulatory 

12 services’’; and 

13 (II) in subclause (II), by insert14 ing ‘‘and hospice care’’ after ‘‘delivery 

15 services’’; and 

16 (ii) in clause (iv), by inserting ‘‘and 

17 (18)’’ after ‘‘(17)’’. 

18 (2) CHIP.—Section 2103(c)(9) of such Act (42 

19 U.S.C. 1397cc(c)(9)), as added by section 

20 211(c)(2)(A), is amended by inserting ‘‘and hospice 

21 care’’ before the period. 

22 (b) EFFECTIVE DATE.—The amendments made sub23 section (a) take effect on January 1, 2011. 


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1 SEC. 228. MEDICARE HOSPICE PAYMENT MODEL DEM2 ONSTRATION PROJECTS. 

3 (a) ESTABLISHMENT.—Not later than July 1, 2012, 

4 the Secretary, acting through the Administrator of the 

5 Centers for Medicare & Medicaid Services and the Direc6 tor of the Agency for Healthcare Research and Quality, 

7 shall conduct demonstration projects to examine ways to 

8 improve how the Medicare hospice care benefit predicts 

9 disease trajectory. Projects shall include the following 

10 models: 

11 (1) Models that better and more appropriately 

12 care for, and transition as needed, patients in their 

13 last years of life who need palliative care, but do not 

14 qualify for hospice care under the Medicare hospice 

15 eligibility criteria. 

16 (2) Models that better and more appropriately 

17 care for long-term patients who are not recertified in 

18 hospice but still need palliative care. 

19 (3) Any other models determined appropriate 

20 by the Secretary. 

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

22 compliance of such requirements of titles XI and XVIII 

23 of the Social Security Act as the Secretary determines nec24 essary to conduct the demonstration projects under this 

25 section. 


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1 (c) REPORTS.—The Secretary shall submit to Con2 gress periodic reports on the demonstration projects con3 ducted under this section. 

4 SEC. 229. MEDPAC STUDIES AND REPORTS. 

5 (a) STUDY AND REPORT REGARDING AN ALTER6 NATIVE PAYMENT METHODOLOGY FOR HOSPICE CARE

7 UNDER THE MEDICARE PROGRAM.— 

8 (1) STUDY.—The Medicare Payment Advisory 

9 Commission (in this section referred to as the ‘‘Com10 mission’’) shall conduct a study on the establishment 

11 of a reimbursement system for hospice care fur12 nished under the Medicare program that is based on 

13 diagnoses. In conducting such study, the Commis14 sion shall use data collected under new provider data 

15 requirements. Such study shall include an analysis 

16 of the following: 

17 (A) Whether such a reimbursement system 

18 better meets patient needs and better cor19 responds with provider resource expenditures 

20 than the current system. 

21 (B) Whether such a reimbursement system 

22 improves quality, including facilitating stand23 ardization of care toward best practices and di24 agnoses-specific clinical pathways in hospice. 


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1 (C) Whether such a reimbursement system 

2 could address concerns about the blanket 6- 

3 month terminal prognosis requirement in hos4 pice. 

5 (D) Whether such a reimbursement system 

6 is more cost effective than the current system. 

7 (E) Any other areas determined appro8 priate by the Commission. 

9 (2) REPORT.—Not later than June 15, 2013, 

10 the Commission shall submit to Congress a report 

11 on the study conducted under subsection (a) to12 gether with recommendations for such legislation 

13 and administrative action as the Commission deter14 mines appropriate. 

15 (b) STUDY AND REPORT REGARDING RURAL HOS16 PICE TRANSPORTATION COSTS UNDER THE MEDICARE

17 PROGRAM.— 

18 (1) STUDY.—The Commission shall conduct a 

19 study on rural Medicare hospice transportation mile20 age to determine potential Medicare reimbursement 

21 changes to account for potential higher costs. 

22 (2) REPORT.—Not later than June 15, 2013, 

23 the Commission shall submit to Congress a report 

24 on the study conducted under subsection (a) to25 gether with recommendations for such legislation 


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1 and administrative action as the Commission deter2 mines appropriate. 

3 (c) EVALUATION OF REIMBURSEMENT DISINCEN4 TIVES TO ELECT MEDICARE HOSPICE WITHIN THE

5 MEDICARE SKILLED NURSING FACILITY BENEFIT.— 

6 (1) STUDY.—The Commission shall conduct a 

7 study to determine potential Medicare reimburse8 ment changes to remove Medicare reimbursement 

9 disincentives for patients in a skilled nursing facility 

10 who want to elect hospice. 

11 (2) REPORT.—Not later than June 15, 2013, 

12 the Commission shall submit to Congress a report 

13 on the study conducted under subsection (a) to14 gether with recommendations for such legislation 

15 and administrative action as the Commission deter16 mines appropriate. 

17 SEC. 230. HHS EVALUATIONS. 

18 (a) EVALUATION OF ACCESS TO HOSPICE AND HOS19 PITAL-BASED PALLIATIVE CARE.— 

20 (1) EVALUATION.—The Secretary, acting 

21 through the Administrator of the Health Resources 

22 and Services Administration, shall conduct an eval23 uation of geographic areas and populations under24 served by hospice and hospital-based palliative care 

25 to identify potential barriers to access. 


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1 (2) REPORT.—Not later than December 31, 

2 2012, the Secretary shall report to Congress, on the 

3 evaluation conducted under subsection (a) together 

4 with recommendations for such legislation and ad5 ministrative action as the Secretary determines ap6 propriate to address barriers to access to hospice 

7 and hospital-based palliative care. 

8 (b) EVALUATION OF AWARENESS AND USE OF HOS9 PICE RESPITE CARE UNDER MEDICARE, MEDICAID, AND

10 CHIP.— 

11 (1) EVALUATION.—The Secretary, acting 

12 through the Director of the Centers for Medicare 

13 and Medicaid Services, shall evaluate the awareness 

14 and use of hospice respite care by informal care15 givers of beneficiaries under Medicare, Medicaid, 

16 and CHIP. 

17 (2) REPORT.—Not later than December 31, 

18 2010, the Secretary shall report to Congress, on the 

19 evaluation conducted under subsection (a) together 

20 with recommendations for such legislation and ad21 ministrative action as the Secretary determines ap22 propriate to increase awareness or use of hospice 

23 respite care under Medicare, Medicaid, and CHIP. 


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1 Subtitle C—Quality Improvement 

2 SEC. 241. PATIENT SATISFACTION SURVEYS. 

3 Not later than January 1, 2012, the Secretary, acting 

4 through the Administrator of the Centers for Medicare & 

5 Medicaid Services, shall establish a mechanism for— 

6 (1) collecting information from patients (or 

7 their health care proxies or families members in the 

8 event patients are unable to speak for themselves) in 

9 relevant provider settings regarding their care at the 

10 end of life; and 

11 (2) incorporating such information in a timely 

12 manner into mechanisms used by the Administrator 

13 to provide quality of care information to consumers, 

14 including the Hospital Compare and Nursing Home 

15 Compare websites maintained by the Administrator. 

16 SEC. 242. DEVELOPMENT OF CORE END-OF-LIFE CARE 

17 QUALITY MEASURES ACROSS EACH REL18 EVANT PROVIDER SETTING. 

19 (a) IN GENERAL.—The Secretary, acting through the 

20 Administrator of the Agency for Healthcare Research and 

21 Quality (in this section referred to as the ‘‘Adminis22 trator’’) and in consultation with the Director of the Na23 tional Institutes of Health, shall require specific end-of24 life quality measures for each relevant provider setting, 


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1 as identified by the Administrator, in accordance with the 

2 requirements of subsection (b). 

3 (b) REQUIREMENTS.—For purposes of subsection 

4 (a), the requirements specified in this subsection are the 

5 following: 

6 (1) Selection of the specific measure or meas7 ures for an identified provider setting shall be— 

8 (A) based on an assessment of what is 

9 likely to have the greatest positive impact on 

10 quality of end-of-life care in that setting; and 

11 (B) made in consultation with affected pro12 viders and public and private organizations, 

13 that have developed such measures. 

14 (2) The measures may be structure-oriented, 

15 process-oriented, or outcome-oriented, as determined 

16 appropriate by the Administrator. 

17 (3) The Administrator shall ensure that report18 ing requirements related to such measures are im19 posed consistent with other applicable laws and reg20 ulations, and in a manner that takes into account 

21 existing measures, the needs of patient populations, 

22 and the specific services provided. 

23 (4) Not later than— 


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1 (A) April 1, 2011, the Secretary shall dis2 seminate the reporting requirements to all af3 fected providers; and 

4 (B) April 1, 2012, initial reporting relating 

5 to the measures shall begin. 

6 SEC. 243. ACCREDITATION OF HOSPITAL-BASED PALLIA7 TIVE CARE PROGRAMS. 

8 (a) IN GENERAL.—The Secretary, acting through the 

9 Director of the Agency for Healthcare Research and Qual10 ity, shall designate a public or private agency, entity, or 

11 organization to develop requirements, standards, and pro12 cedures for accreditation of hospital-based palliative care 

13 programs. 

14 (b) REPORTING.—Not later than January 1, 2012, 

15 the Secretary shall prepare and submit a report to Con16 gress on the proposed accreditation process for hospital17 based palliative care programs. 

18 (c) ACCREDITATION.—Not later than July 1, 2012, 

19 the Secretary shall— 

20 (1) establish and promulgate standards and 

21 procedures for accreditation of hospital-based pallia22 tive care programs; and 

23 (2) designate an agency, entity, or organization 

24 that shall be responsible for certifying such proVerDate Nov 24 2008 23:09 May 26, 2009 Jkt 079200 PO 00000 Frm 00081 Fmt 6652 Sfmt 6201 E:\BILLS\S1150.IS S1150

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1 grams in accordance with the standards established 

2 under paragraph (1). 

3 (d) DEFINITIONS.—For the purposes of this section: 

4 (1) The term ‘‘hospital-based palliative care 

5 program’’ means a hospital-based program that is 

6 comprised of an interdisciplinary team that special7 izes in providing palliative care services and con8 sultations in a variety of health care settings, includ9 ing hospitals, nursing homes, and home and commu10 nity-based services. 

11 (2) The term ‘‘interdisciplinary team’’ means a 

12 group of health care professionals (consisting of, at 

13 a minimum, a doctor, a nurse, and a social worker) 

14 that have received specialized training in palliative 

15 care. 

16 SEC. 244. SURVEY AND DATA REQUIREMENTS FOR ALL 

17 MEDICARE PARTICIPATING HOSPICE PRO18 GRAMS. 

19 (a) HOSPICE SURVEYS.—Section 1861(dd) of the So20 cial Security Act (42 U.S.C. 1395x(dd)) is amended by 

21 adding at the end the following new paragraph: 

22 ‘‘(6) In accordance with the recommendations of the 

23 Medicare Payment Advisory Commission contained in the 

24 March 2009 report entitled ‘Report to Congress: Medicare 

25 Payment Policy’, the Secretary shall establish, effective 


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1 July 1, 2010, the following survey requirements for hos2 pice programs: 

3 ‘‘(A) Any hospice program seeking initial cer4 tification under this title on or after that date shall 

5 be subject to an initial survey by an appropriate 

6 State or local agency, or an approved accreditation 

7 agency, not later than 6 months after the program 

8 first seeks such certification. 

9 ‘‘(B) All hospice programs certified for partici10 pation under this title shall be subject to a standard 

11 survey by an appropriate State or local agency, or 

12 an approved accreditation agency, at least every 3 

13 years after initially being so certified.’’. 

14 (b) REQUIRED HOSPICE RESOURCE INPUTS DATA.— 

15 Section 1861(dd) of the Social Security Act (42 U.S.C. 

16 1395x(dd)), as amended by subsection (a), is amended— 

17 (1) in paragraph (3)— 

18 (A) in subparagraph (F), by striking 

19 ‘‘and’’ at the end; 

20 (B) by redesignating subparagraph (G) as 

21 subparagraph (H); and 

22 (C) by inserting after subparagraph (F) 

23 the following new subparagraph: 

24 ‘‘(G) to comply with the reporting requirements 

25 under paragraph (7); and’’; and 


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1 (2) by adding at the end the following new 

2 paragraph: 

3 ‘‘(7)(A) In accordance with the recommenda4 tions of the Medicare Payment Advisory Commission 

5 for additional data (as contained in the March 2009 

6 report entitled ‘Report to Congress: Medicare Pay7 ment Policy’), beginning January 1, 2011, a hospice 

8 program shall report to the Secretary, in such form 

9 and manner, and at such intervals, as the Secretary 

10 shall require, the following data with respect to each 

11 patient visit: 

12 ‘‘(i) Visit type (such as admission, routine, 

13 emergency, education for family, other). 

14 ‘‘(ii) Visit length. 

15 ‘‘(iii) Professional or paraprofessional dis16 ciplines involved in the visit, including nurse, 

17 social worker, home health aide, physician, 

18 nurse practitioner, chaplain or spiritual coun19 selor, counselor, dietician, physical therapist, 

20 occupational therapist, speech language patholo21 gist, music or art therapist, and including be22 reavement and support services provided to a 

23 family after a patient’s death. 

24 ‘‘(iv) Drugs and other therapeutic inter25 ventions provided. 


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1 ‘‘(v) Home medical equipment and other 

2 medical supplies provided. 

3 ‘‘(B) In collecting the data required under sub4 paragraph (A), the Secretary shall ensure that the 

5 data are reported in a manner that allows for sum6 marized cross-tabulations of the data by patients’ 

7 terminal diagnoses, lengths of stay, age, sex, and 

8 race.’’. 

9 Subtitle D—Additional Reports, 

10 Research, and Evaluations 

11 SEC. 251. NATIONAL CENTER ON PALLIATIVE AND END-OF12 LIFE CARE. 

13 Part E of title IV of the Public Health Service Act 

14 (42 U.S.C. 287 et seq.) is amended by adding at the end 

15 the following: 

16 ‘‘Subpart 7—National Center on Palliative and End17 of-Life Care 

18 ‘‘SEC. 485J. NATIONAL CENTER ON PALLIATIVE AND END19 OF-LIFE CARE. 

20 ‘‘(a) ESTABLISHMENT.—Not later than July 1, 2011, 

21 there shall be established within the National Institutes 

22 of Health, a National Center on Palliative and End-of23 Life Care (referred to in this section as the ‘Center’). 


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1 ‘‘(b) PURPOSE.—The general purpose of the Center 

2 is to conduct and support research relating to palliative 

3 and end-of-life care interventions and approaches. 

4 ‘‘(c) ACTIVITIES.—The Center shall— 

5 ‘‘(1) develop and continuously update a re6 search agenda with the goal of— 

7 ‘‘(A) providing a better biomedical under8 standing of the end of life; and 

9 ‘‘(B) improving the quality of care and life 

10 at the end of life; and 

11 ‘‘(2) provide funding for peer-review-selected 

12 extra- and intra-mural research that includes the 

13 evaluation of existing, and the development of new, 

14 palliative and end-of-life care interventions and ap15 proaches.’’. 

16 SEC. 252. NATIONAL MORTALITY FOLLOWBACK SURVEY. 

17 (a) IN GENERAL.—Not later than December 31, 

18 2010, and annually thereafter, the Secretary, acting 

19 through the Director of the Centers for Disease Control 

20 and Prevention, shall renew and conduct the National 

21 Mortality Followback Survey (referred to in this section 

22 as the ‘‘Survey’’) to collect data on end-of-life care. 

23 (b) PURPOSE.—The purpose of the Survey shall be 

24 to gain a better understanding of current end-of-life care 

25 in the United States. 


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1 (c) QUESTIONS.— 

2 (1) IN GENERAL.—In conducting the Survey, 

3 the Director of the Centers for Disease Control and 

4 Prevention shall, at a minimum, include the fol5 lowing questions with respect to the loved one of a 

6 respondent: 

7 (A) Did he or she have an advance direc8 tive, and if so, when it was completed. 

9 (B) Did he or she have an order for life10 sustaining treatment, and if so, when was it 

11 completed. 

12 (C) Did he or she have a durable power of 

13 attorney, and if so, when it was completed. 

14 (D) Had he or she discussed his or her 

15 wishes with loved ones, and if so, when. 

16 (E) Had he or she discussed his or her 

17 wishes with his or her physician, and if so, 

18 when. 

19 (F) In the opinion of the respondent, was 

20 he or she satisfied with the care he or she re21 ceived in the last year of life and in the last 

22 week of life. 

23 (G) Was he or she cared for by hospice, 

24 and if so, when. 


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1 (H) Was he or she cared for by palliative 

2 care specialists, and if so, when. 

3 (I) Did he or she receive effective pain 

4 management (if needed). 

5 (J) What was the experience of the main 

6 caregiver (including if such caregiver was the 

7 respondent), and whether he or she received 

8 sufficient support in this role. 

9 (2) ADDITIONAL QUESTIONS.—Additional ques10 tions to be asked during the Survey shall be deter11 mined by the Director of the Centers for Disease 

12 Control and Prevention on an ongoing basis with 

13 input from relevant research entities. 

14 SEC. 253. DEMONSTRATION PROJECTS FOR USE OF TELE15 MEDICINE SERVICES IN ADVANCE CARE 

16 PLANNING. 

17 (a) IN GENERAL.—Not later than July 1, 2013, the 

18 Secretary shall establish a demonstration program to re19 imburse eligible entities for costs associated with the use 

20 of telemedicine services (including equipment and connec21 tion costs) to provide advance care planning consultations 

22 with geographically distant physicians and their patients. 

23 (b) DURATION.—The demonstration project under 

24 this section shall be conducted for at least a 3-year period. 

25 (c) DEFINITIONS.—For purposes of this section: 


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1 (1) The term ‘‘eligible entity’’ means a physi2 cian or an advance practice nurse who provides serv3 ices pursuant to a hospital-based palliative care pro4 gram (as defined in section 262(d)(1)). 

5 (2) The term ‘‘geographically distant’’ has the 

6 meaning given that term by the Secretary for pur7 poses of conducting the demonstration program es8 tablished under this section. 

9 (3) The term ‘‘telemedicine services’’ means a 

10 service or consultation provided via telecommuni11 cation equipment that allows an eligible entity to ex12 change or discuss medical information with a patient 

13 or a health care professional at a separate location 

14 through real-time videoconferencing, or a similar for15 mat, for the purpose of providing health care diag16 nosis and treatment. 

17 (d) FUNDING.—There are authorized to be appro18 priated to the Secretary such sums as may be necessary 

19 to carry out this section. 

20 SEC. 254. INSPECTOR GENERAL INVESTIGATION OF FRAUD 

21 AND ABUSE. 

22 In accordance with the recommendations of the Medi23 care Payment Advisory Commission for additional data 

24 (as contained in the March 2009 report entitled ‘‘Report 

25 to Congress: Medicare Payment Policy’’), the Secretary 


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1 shall direct the Office of the Inspector General of the De2 partment of Health and Human Services to investigate, 

3 not later than January 1, 2012, the following with respect 

4 to hospice benefit under Medicare, Medicaid, and CHIP: 

5 (1) The prevalence of financial relationships be6 tween hospices and long-term care facilities, such as 

7 nursing facilities and assisted living facilities, that 

8 may represent a conflict of interest and influence ad9 missions to hospice. 

10 (2) Differences in patterns of nursing home re11 ferrals to hospice. 

12 (3) The appropriateness of enrollment practices 

13 for hospices with unusual utilization patterns (such 

14 as high frequency of very long stays, very short 

15 stays, or enrollment of patients discharged from 

16 other hospices). 

17 (4) The appropriateness of hospice marketing 

18 materials and other admissions practices and poten19 tial correlations between length of stay and defi20 ciencies in marketing or admissions practices. 

21 SEC. 255. GAO STUDY AND REPORT ON PROVIDER ADHER22 ENCE TO ADVANCE DIRECTIVES. 

23 Not later than January 1, 2012, the Comptroller 

24 General of the United States shall conduct a study of the 

25 extent to which providers comply with advance directives 


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1 under the Medicare and Medicaid programs and shall sub2 mit a report to Congress on the results of such study, to3 gether with such recommendations for administrative or 

4 legislative changes as the Comptroller General determines 

5 appropriate. 

Æ 


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