I 

111TH CONGRESS 

1ST SESSION H. R. 2911 

To improve end-of-life care. 

IN THE HOUSE OF REPRESENTATIVES 

JUNE 17, 2009 

Mr. BLUMENAUER (for himself, Ms. BALDWIN, Mr. LEVIN, and Mr. 

PASCRELL) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on 

Ways and Means and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions 

as fall within the jurisdiction of the committee concerned 

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. 


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TITLE I—ADVANCE CARE PLANNING 

Subtitle A—Consumer and Provider Education 

PART I—CONSUMER EDUCATION

SUBPART A—NATIONAL INITIATIVES

Sec. 101. Advance care planning telephone hotline. 

Sec. 102. Advance care planning information clearinghouses. 

Sec. 103. Advance care planning toolkit. 

Sec. 104. National public education campaign. 

Sec. 105. Update of Medicare and Social Security handbooks. 

Sec. 106. Authorization of appropriations. 

SUBPART B—STATE AND LOCAL INITIATIVES

Sec. 111. Financial assistance for advance care planning. 

Sec. 112. Grants for programs for orders regarding life sustaining treatment. 

PART II—PROVIDER EDUCATION

Sec. 121. Public provider advance care planning website. 

Sec. 122. Continuing education for physicians and nurses. 

Subtitle B—Portability of Advance Directives; Health Information Technology 

Sec. 131. Portability of advance directives. 

Sec. 132. State advance directive registries; driver’s license advance directive 

notation. 

Sec. 133. GAO study and report on establishment of national advance directive 

registry. 

Subtitle C—National Uniform Policy on Advance Care Planning 

Sec. 141. Study and report by the Secretary regarding the establishment and 

implementation of a national uniform policy on advance directives. 

TITLE II—COMPASSIONATE CARE 

Subtitle A—Workforce Development 

PART I—EDUCATION AND TRAINING

Sec. 201. National Geriatric and Palliative Care Services Corps. 

Sec. 202. Exemption of palliative medicine fellowship training from Medicare 

graduate medical education caps. 

Sec. 203. Medical school curricula. 

Subtitle B—Coverage Under Medicare, Medicaid, and CHIP 

PART I—COVERAGE OF ADVANCE CARE PLANNING

Sec. 211. Medicare, Medicaid, and CHIP coverage. 

PART II—HOSPICE

Sec. 221. Adoption of MedPAC hospice payment methodology recommendations. 


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Sec. 222. Removing hospice inpatient days in setting per diem rates for critical 

access hospitals. 

Sec. 223. Hospice payments for dual eligible individuals residing in long-term 

care facilities. 

Sec. 224. Delineation of respective care responsibilities of hospice programs and 

long-term care facilities. 

Sec. 225. Adoption of MedPAC hospice program eligibility certification and recertification recommendations. 

Sec. 226. Concurrent care for children. 

Sec. 227. Making hospice a required benefit under Medicaid and CHIP. 

Sec. 228. Medicare Hospice payment model demonstration projects. 

Sec. 229. MedPAC studies and reports. 

Sec. 230. HHS Evaluations. 

Subtitle C—Quality Improvement 

Sec. 241. Patient satisfaction surveys. 

Sec. 242. Development of core end-of-life care quality measures across each relevant provider setting. 

Sec. 243. Accreditation of hospital-based palliative care programs. 

Sec. 244. Survey and data requirements for all Medicare participating hospice 

programs. 

Subtitle D—Additional Reports, Research, and Evaluations 

Sec. 251. National Center on Palliative and End-of-Life Care. 

Sec. 252. National Mortality Followback Survey. 

Sec. 253. Demonstration projects for use of telemedicine services in advance 

care planning. 

Sec. 254. Inspector General investigation of fraud and abuse. 

Sec. 255. GAO study and report on provider adherence to advance directives. 

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— 


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

2 (ii) what the future may hold for peo3 ple with serious illnesses or injuries; 

4 (iii) how individuals, their health care 

5 proxies, and family members want their be6 liefs and preferences to guide care deci7 sions; and 

8 (iv) the steps that individuals and 

9 family members can take regarding, and 

10 the resources available to help with, fi11 nances, family matters, spiritual questions, 

12 and other issues that impact seriously ill or 

13 dying patients and their families; and 

14 (C) executing and updating advance direc15 tives and appointing a health care proxy. 

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

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

18 health care power of attorney, durable power of at19 torney, or other written statement by a competent 

20 individual that is recognized under State law and in21 dicates the individual’s wishes regarding medical 

22 treatment in the event of future incompetence. Such 

23 term includes an advance health care directive and 

24 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 sion maker for a patient who has the authority to 

13 act on the patient’s behalf when the patient is un14 able to communicate his or her wishes for medical 

15 care on matters that the patient specifies when he 

16 or she is competent. Such term includes a durable 

17 power of 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 (C) available Federal and State-specific re21 sources for assistance with advance care plan22 ning, including— 

23 (i) contact information for any State 

24 public health departments that are respon25 sible for issues regarding end-of-life care; 


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1 (ii) contact information for relevant 

2 legal service organizations, including those 

3 funded under the Older Americans Act of 

4 1965 (42 U.S.C. 3001 et seq.); and 

5 (iii) advance directive forms for each 

6 State; and 

7 (D) any additional information, as deter8 mined by the Secretary. 

9 (b) ESTABLISHMENT OF PEDIATRIC ADVANCE CARE

10 PLANNING CLEARINGHOUSE.— 

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

12 2011, the Secretary, in consultation with the Assist13 ant Secretary for Children and Families of the De14 partment of Health and Human Services, shall de15 velop an online clearinghouse to provide comprehen16 sive information regarding pediatric advance care 

17 planning. 

18 (2) MAINTENANCE.—The pediatric advance 

19 care planning clearinghouse, which shall be clearly 

20 identifiable on the homepage of the Administration 

21 for Children and Families website, shall be main22 tained and publicized by the Secretary on an ongo23 ing basis. 

24 (3) CONTENT.—The pediatric advance care 

25 planning clearinghouse shall provide advance care 


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1 planning information specific to children with life2 threatening illnesses or injuries and their families. 

3 SEC. 103. ADVANCE CARE PLANNING TOOLKIT. 

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

5 the Secretary, in consultation with the Director of the 

6 Centers for Disease Control and Prevention, shall develop 

7 an online advance care planning toolkit. 

8 (b) MAINTENANCE.—The advance care planning tool9 kit, which shall be available in English, Spanish, and any 

10 other languages that the Secretary deems appropriate, 

11 shall be maintained and publicized by the Secretary on an 

12 ongoing basis and made available on the following 

13 websites: 

14 (1) The Centers for Disease Control and Pre15 vention. 

16 (2) The Department of Health and Human 

17 Service’s National Clearinghouse for Long-Term 

18 Care Information. 

19 (3) The Administration for Children and Fami20 lies. 

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

22 shall include content addressing— 

23 (1) common issues and questions regarding ad24 vance care planning, including individuals and re25 sources to contact for further inquiries; 


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1 (2) advance directives and their uses, including 

2 living wills and durable powers of attorney; 

3 (3) the roles and responsibilities of a health 

4 care proxy; 

5 (4) Federal and State-specific resources to as6 sist individuals and their families with advance care 

7 planning, including— 

8 (A) the advance care planning toll-free 

9 telephone hotline established under section 101; 

10 (B) the advance care planning clearing11 houses established under section 102; 

12 (C) the advance care planning toolkit es13 tablished under this section; 

14 (D) available State legal service organiza15 tions to assist individuals with advance care 

16 planning, including those organizations that re17 ceive funding pursuant to the Older Americans 

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

19 (E) website links or addresses for State20 specific advance directive forms; and 

21 (5) any additional information, as determined 

22 by the Secretary. 

23 SEC. 104. NATIONAL PUBLIC EDUCATION CAMPAIGN. 

24 (a) NATIONAL PUBLIC EDUCATION CAMPAIGN.— 


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

2 2011, the Secretary, acting through the Director of 

3 the Centers for Disease Control and Prevention, 

4 shall, directly or through grants, contracts, or inter5 agency agreements, develop and implement a na6 tional campaign to inform the public of the impor7 tance of advance care planning and of an individ8 ual’s right to direct and participate in their health 

9 care decisions. 

10 (2) CONTENT OF EDUCATIONAL CAMPAIGN.— 

11 The national public education campaign established 

12 under paragraph (1) shall— 

13 (A) employ the use of various media, in14 cluding regularly televised public service an15 nouncements; 

16 (B) provide culturally and linguistically ap17 propriate information; 

18 (C) be conducted continuously over a pe19 riod of not less than 5 years; 

20 (D) identify and promote the advance care 

21 planning information available on the Depart22 ment of Health and Human Service’s National 

23 Clearinghouse for Long-Term Care Information 

24 website and Administration for Children and 

25 Families website, as well as any other relevant 


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1 Federal or State-specific advance care planning 

2 resources; 

3 (E) raise public awareness of the con4 sequences that may result if an individual is no 

5 longer able to express or communicate their 

6 health care decisions; 

7 (F) address the importance of individuals 

8 speaking to family members, health care prox9 ies, and health care providers as part of an on10 going dialogue regarding their health care 

11 choices; 

12 (G) address the need for individuals to ob13 tain readily available legal documents that ex14 press their health care decisions through ad15 vance directives (including living wills, comfort 

16 care orders, and durable powers of attorney for 

17 health care); 

18 (H) raise public awareness regarding the 

19 availability of hospice and palliative care; and 

20 (I) encourage individuals to speak with 

21 their physicians about their options and inten22 tions for end-of-life care. 

23 (3) EVALUATION.— 

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

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1 tor of the Centers for Disease Control and Pre2 vention, shall conduct a nationwide survey to 

3 evaluate whether the national campaign con4 ducted under this subsection has achieved its 

5 goal of changing public awareness, attitudes, 

6 and behaviors regarding advance care planning. 

7 (B) BASELINE SURVEY.—In order to 

8 evaluate the effectiveness of the national cam9 paign, the Secretary shall conduct a baseline 

10 survey prior to implementation of the campaign. 

11 (C) REPORTING REQUIREMENT.—Not later 

12 than December 31, 2013, the Secretary shall 

13 report the findings of such survey, as well as 

14 any recommendations that the Secretary deter15 mines appropriate regarding the need for con16 tinuation or legislative or administrative 

17 changes to facilitate changing public awareness, 

18 attitudes, and behaviors regarding advance care 

19 planning, to the appropriate committees of the 

20 Congress. 

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

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

23 Public Law 101–508) is repealed. 


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1 SEC. 105. UPDATE OF MEDICARE AND SOCIAL SECURITY 

2 HANDBOOKS. 

3 (a) MEDICARE & YOU HANDBOOK.— 

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

5 the date of enactment of this Act, the Secretary 

6 shall update the online version of the ‘‘Planning 

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

8 include— 

9 (A) an explanation of advance care plan10 ning and advance directives, including— 

11 (i) living wills; 

12 (ii) health care proxies; and 

13 (iii) after-death directives; 

14 (B) Federal and State-specific resources to 

15 assist individuals and their families with ad16 vance care planning, including— 

17 (i) the advance care planning toll-free 

18 telephone hotline established under section 

19 101; 

20 (ii) the advance care planning clear21 inghouses established under section 102; 

22 (iii) the advance care planning toolkit 

23 established under section 103; 

24 (iv) available State legal service orga25 nizations to assist individuals with advance 

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1 tions that receive funding pursuant to the 

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

3 3001 et seq.); and 

4 (v) website links or addresses for 

5 State-specific advance directive forms; and 

6 (C) any additional information, as deter7 mined by the Secretary. 

8 (2) UPDATE OF PAPER AND SUBSEQUENT

9 VERSIONS.—The Secretary shall include the infor10 mation described in paragraph (1) in all paper and 

11 electronic versions of the Medicare & You Handbook 

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

13 days after the date of enactment of this Act. 

14 (b) SOCIAL SECURITY HANDBOOK.—The Commis15 sioner of Social Security shall— 

16 (1) not later than 60 days after the date of en17 actment of this Act, update the online version of the 

18 Social Security Handbook for beneficiaries to include 

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

20 (2) include such information in all paper and 

21 online versions of such handbook that are published 

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

23 of enactment of this Act. 


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1 SEC. 106. AUTHORIZATION OF APPROPRIATIONS. 

2 There is authorized to be appropriated for the period 

3 of fiscal years 2010 through 2014— 

4 (1) $195,000,000 to the Secretary to carry out 

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

6 (2) $5,000,000 to the Commissioner of Social 

7 Security to carry out section 105(b). 

8 Subpart B—State and Local Initiatives 

9 SEC. 111. FINANCIAL ASSISTANCE FOR ADVANCE CARE 

10 PLANNING. 

11 (a) LEGAL ASSISTANCE FOR ADVANCE CARE PLAN12 NING.— 

13 (1) DEFINITION OF RECIPIENT.—Section 

14 1002(6) of the Legal Services Corporation Act (42 

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

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

17 (2) ADVANCE CARE PLANNING.—Section 1006 

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

19 2996e) is amended— 

20 (A) in subsection (a)(1)— 

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

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

23 ‘‘(C) to make’’; and 

24 (ii) by inserting after subparagraph 

25 (A) the following: 


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

2 grants and contracts, as described in subparagraph 

3 (A), on a competitive basis for the purpose of pro4 viding legal assistance in the form of advance care 

5 planning (as defined in section 3 of the Advance 

6 Planning and Compassionate Care Act of 2009, and 

7 including providing information about State-specific 

8 advance directives, as defined in that section) for eli9 gible clients under this title, including providing 

10 such planning to the family members of eligible cli11 ents and persons with power of attorney to make 

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

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

14 the following: 

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

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

17 the Assisted Suicide Funding Restriction Act of 1997 (42 

18 U.S.C. 14401 et seq.).’’. 

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

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

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

22 Corporation shall require such a report, on an an23 nual basis, from each grantee, contractor, or other 

24 recipient of financial assistance under section 

25 1006(a)(1)(B).’’. 


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1 (4) AUTHORIZATION OF APPROPRIATIONS.— 

2 Section 1010 of the Legal Services Corporation Act 

3 (42 U.S.C. 2996i) is amended— 

4 (A) in subsection (a)— 

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

6 ‘‘(a)(1)’’; 

7 (ii) in the last sentence, by striking 

8 ‘‘Appropriations for that purpose’’ and in9 serting the following: 

10 ‘‘(3) Appropriations for a purpose described in para11 graph (1) or (2)’’; and 

12 (iii) by inserting before paragraph (3) 

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

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

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

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

17 (B) in subsection (d), by striking ‘‘sub18 section (a)’’ and inserting ‘‘subsection (a)(1)’’. 

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

20 amendments made by this subsection take effect 

21 July 1, 2010. 

22 (b) STATE HEALTH INSURANCE ASSISTANCE PRO23 GRAMS.— 

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

25 amounts made available under paragraph (3) to 


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1 award grants to States for State health insurance 

2 assistance programs receiving assistance under sec3 tion 4360 of the Omnibus Budget Reconciliation Act 

4 of 1990 to provide advance care planning services to 

5 Medicare beneficiaries, personal representatives of 

6 such beneficiaries, and the families of such bene7 ficiaries. Such services shall include information re8 garding State-specific advance directives and ways to 

9 discuss individual care wishes with health care pro10 viders. 

11 (2) REQUIREMENTS.— 

12 (A) AWARD OF GRANTS.—In making 

13 grants under this subsection for a fiscal year, 

14 the Secretary shall satisfy the following require15 ments: 

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

17 funds available under paragraph (3) for a 

18 fiscal year shall be allocated among those 

19 States approved for a grant under this sec20 tion that have adopted the Uniform 

21 Health-Care Decisions Act drafted by the 

22 National Conference of Commissioners on 

23 Uniform State Laws and approved and 

24 recommended for enactment by all States 


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1 at the annual conference of such commis2 sioners in 1993. 

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

4 funds available under paragraph (3) for a 

5 fiscal year shall be allocated among those 

6 States approved for a grant under this sec7 tion that have adopted a uniform form for 

8 orders regarding life sustaining treatment 

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

10 Social Security Act (as amended by section 

11 211 of this Act) or a comparable approach 

12 to advance care planning. 

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

14 of being awarded a grant under this subsection, 

15 a State shall submit the following to the Sec16 retary: 

17 (i) An approved plan for expending 

18 grant funds. 

19 (ii) For each fiscal year for which the 

20 State is paid grant funds under this sub21 section, an annual report regarding the use 

22 of the funds, including the number of 

23 Medicare beneficiaries served and their sat24 isfaction with the services provided. 


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

2 funds from a grant made under this subsection 

3 prior to July 1, 2010. 

4 (3) AUTHORIZATION OF APPROPRIATIONS.— 

5 There is authorized to be appropriated to the Sec6 retary to the Centers for Medicare & Medicaid Serv7 ices Program Management Account, $12,000,000 for 

8 each of fiscal years 2010 through 2014 for purposes 

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

10 (c) MEDICAID TRANSFORMATION GRANTS FOR AD11 VANCE CARE PLANNING.—Section 1903(z) of the Social 

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

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

14 following new subparagraph: 

15 ‘‘(G) Methods for improving the effective16 ness and efficiency of medical assistance pro17 vided under this title by making available to in18 dividuals enrolled in the State plan or under a 

19 waiver of such plan information regarding ad20 vance care planning (as defined in section 3 of 

21 the Advance Planning and Compassionate Care 

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

23 renewal of enrollment in the plan or waiver, 

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1 novative means as the State determines appro2 priate.’’; 

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

4 following new subparagraph: 

5 ‘‘(D) WORK PLAN REQUIRED FOR AWARD

6 OF ADVANCE CARE PLANNING GRANTS.—Pay7 ment to a State under this subsection to adopt 

8 the innovative methods described in paragraph 

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

10 the Secretary an approved plan for expending 

11 the funds awarded to the State under this sub12 section.’’; and 

13 (3) in paragraph (4)— 

14 (A) in subparagraph (A)— 

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

16 the end; 

17 (ii) in clause (ii), by striking the pe18 riod at the end and inserting ‘‘; and’’; and 

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

20 following new clause: 

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

22 years 2010 through 2014.’’; and 

23 (B) by striking subparagraph (B), and in24 serting the following: 


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1 ‘‘(B) ALLOCATION OF FUNDS.—The Sec2 retary shall specify a method for allocating the 

3 funds made available under this subsection 

4 among States awarded a grant for fiscal year 

5 2010, 2011, 2012, 2013, or 2014. Such method 

6 shall provide that— 

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

8 each of fiscal years 2010 through 2014 

9 shall be awarded to States that design pro10 grams to adopt the innovative methods de11 scribed in paragraph (2)(G); and 

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

13 State awarded a grant under this sub14 section for fiscal year 2010 be made prior 

15 to July 1, 2010.’’. 

16 (d) ADVANCE CARE PLANNING COMMUNITY TRAIN17 ING GRANTS.— 

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

19 amounts made available under paragraph (3) to 

20 award grants to area agencies on aging (as defined 

21 in section 102 of the Older Americans Act of 1965 

22 (42 U.S.C. 3002)). 

23 (2) REQUIREMENTS.— 

24 (A) USE OF FUNDS.—Funds awarded to 

25 an area agency on aging under this subsection 


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1 shall be used to provide advance care planning 

2 education and training opportunities for local 

3 aging service providers and organizations. 

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

5 of being awarded a grant under this subsection, 

6 an area agency on aging shall submit the fol7 lowing to the Secretary: 

8 (i) An approved plan for expending 

9 grant funds. 

10 (ii) For each fiscal year for which the 

11 agency is paid grant funds under this sub12 section, an annual report regarding the use 

13 of the funds, including the number of 

14 Medicare beneficiaries served and their sat15 isfaction with the services provided. 

16 (C) LIMITATION.—No area agency on 

17 aging shall be paid funds from a grant made 

18 under this subsection prior to July 1, 2010. 

19 (3) AUTHORIZATION OF APPROPRIATIONS.— 

20 There is authorized to be appropriated to the Sec21 retary to the Centers for Medicare & Medicaid Serv22 ices Program Management Account, $12,000,000 for 

23 each of fiscal years 2010 through 2014 for purposes 

24 of awarding grants to area agencies on aging under 

25 paragraph (1). 


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1 (e) NONDUPLICATION OF ACTIVITIES.—The Sec2 retary shall establish procedures to ensure that funds 

3 made available under grants awarded under this section 

4 or pursuant to amendments made by this section supple5 ment, not supplant, existing Federal funding, and that 

6 such funds are not used to duplicate activities carried out 

7 under such grants or under other federally funded pro8 grams. 

9 SEC. 112. GRANTS FOR PROGRAMS FOR ORDERS REGARD10 ING LIFE SUSTAINING TREATMENT. 

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

12 to eligible entities for the purpose of— 

13 (1) establishing new programs for orders re14 garding life sustaining treatment in States or local15 ities; 

16 (2) expanding or enhancing an existing pro17 gram for orders regarding life sustaining treatment 

18 in States or localities; or 

19 (3) providing a clearinghouse of information on 

20 programs for orders for life sustaining treatment 

21 and consultative services for the development or en22 hancement of such programs. 

23 (b) AUTHORIZED ACTIVITIES.—Activities funded 

24 through a grant under this section for an area may in25 clude— 


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

2 includes home care, hospice, long-term care, commu3 nity and assisted living residences, skilled nursing 

4 facilities, inpatient rehabilitation facilities, hospitals, 

5 and emergency medical services within the area; 

6 (2) securing consultative services and advice 

7 from institutions with experience in developing and 

8 managing such programs; and 

9 (3) expanding an existing program for orders 

10 regarding life sustaining treatment to serve more pa11 tients or enhance the quality of services, including 

12 educational services for patients and patients’ fami13 lies or training of health care professionals. 

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

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

16 funds appropriated to carry out this section for each fiscal 

17 year— 

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

19 or developing new programs for orders regarding life 

20 sustaining treatment; and 

21 (2) one-third is used for expanding or enhanc22 ing existing programs for orders regarding life sus23 taining treatment. 

24 (d) DEFINITIONS.—In this section: 

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


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1 (A) an academic medical center, a medical 

2 school, a State health department, a State med3 ical association, a multi-State taskforce, a hos4 pital, or a health system capable of admin5 istering a program for orders regarding life sus6 taining treatment for a State or locality; or 

7 (B) any other health care agency or entity 

8 as the Secretary determines appropriate. 

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

10 treatment’’ has the meaning given such term in sec11 tion 1861(hhh)(5) of the Social Security Act, as 

12 added by section 211. 

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

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

15 area, a program that supports the active use of or16 ders regarding life sustaining treatment in the area. 

17 (e) AUTHORIZATION OF APPROPRIATIONS.—To carry 

18 out this section, there are authorized to be appropriated 

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

20 2009 through 2014. 

21 PART II—PROVIDER EDUCATION 

22 SEC. 121. PUBLIC PROVIDER ADVANCE CARE PLANNING 

23 WEBSITE. 

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

25 2010, the Secretary, acting through the Administrator of 


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1 the Centers for Medicare & Medicaid Services and the Di2 rector of the Agency for Healthcare Research and Quality, 

3 shall establish a website for providers under Medicare, 

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

5 Indian Health Service (include contract providers) and 

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

7 make decisions concerning medical care, including the 

8 right to accept or refuse medical or surgical treatment, 

9 and the existence of advance directives. 

10 (b) MAINTENANCE.—The website, shall be main11 tained and publicized by the Secretary on an ongoing 

12 basis. 

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

14 tools, and resources necessary to do the following: 

15 (1) Inform providers about the advance direc16 tive requirements under the health care programs 

17 described in subsection (a) and other State and Fed18 eral laws and regulations related to advance care 

19 planning. 

20 (2) Educate providers about advance care plan21 ning quality improvement activities. 

22 (3) Provide assistance to providers to— 

23 (A) integrate advance directives into elec24 tronic health records, including oral directives; 

25 and 


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1 (B) develop and disseminate advance care 

2 planning informational materials for their pa3 tients. 

4 (4) Inform providers about advance care plan5 ning continuing education requirements and oppor6 tunities. 

7 (5) Encourage providers to discuss advance 

8 care planning with their patients of all ages. 

9 (6) Assist providers’ understanding of the con10 tinuum of end-of-life care services and supports 

11 available to patients, including palliative care and 

12 hospice. 

13 (7) Inform providers of best practices for dis14 cussing end-of-life care with dying patients and their 

15 loved ones. 

16 SEC. 122. CONTINUING EDUCATION FOR PHYSICIANS AND 

17 NURSES. 

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

19 the Secretary, acting through the Director of Health Re20 sources and Services Administration, shall develop, in con21 sultation with health care providers and State boards of 

22 medicine and nursing, a curriculum for continuing edu23 cation that States may adopt for physicians and nurses 

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

25 (b) CONTENT.— 


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1 (1) IN GENERAL.—The continuing education 

2 curriculum developed under subsection (a) for physi3 cians and nurses shall, at a minimum, include— 

4 (A) a description of the meaning and im5 portance of advance care planning; 

6 (B) a description of advance directives, in7 cluding living wills and durable powers of attor8 ney, and the use of such directives; 

9 (C) palliative care principles and ap10 proaches to care; and 

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

12 and supports, including palliative care and hos13 pice. 

14 (2) ADDITIONAL CONTENT FOR PHYSICIANS.— 

15 The continuing education curriculum for physicians 

16 developed under subsection (a) shall include instruc17 tion on how to conduct advance care planning with 

18 patients and their loved ones. 

19 Subtitle B—Portability of Advance 

20 Directives; Health Information 

21 Technology 

22 SEC. 131. PORTABILITY OF ADVANCE DIRECTIVES. 

23 (a) MEDICARE.—Section 1866(f) of the Social Secu24 rity Act (42 U.S.C. 1395cc(f)) is amended— 

25 (1) in paragraph (1)— 


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

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

3 the content of such advance directive in a 

4 prominent part of such record’’ before the semi5 colon at the end; 

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

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

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

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

10 (D) by inserting after subparagraph (E) 

11 the following new subparagraph: 

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

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

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

18 and inserting ‘‘an’’; and 

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

20 paragraph: 

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

22 of the State in which such advance directive is presented 

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

24 Advantage organization, or a prepaid or eligible organiza25 tion shall be given the same effect by that provider or orVerDate Nov 24 2008 03:55 Jun 20, 2009 Jkt 079200 PO 00000 Frm 00033 Fmt 6652 Sfmt 6201 E:\BILLS\H2911.IH H2911

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1 ganization as an advance directive validly executed under 

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

3 effect. 

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

5 also include actual knowledge of instructions made while 

6 an individual was able to express the wishes of such indi7 vidual with regard to health care. 

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

9 knowledge’ means the possession of information of an indi10 vidual’s wishes communicated to the health care provider 

11 orally or in writing by the individual, the individual’s med12 ical power of attorney representative, the individual’s 

13 health care surrogate, or other individuals resulting in the 

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

15 Other forms of imputed knowledge are not actual knowl16 edge. 

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

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

19 such provisions. The provisions of this paragraph shall not 

20 preempt any State law that provides for greater port21 ability, more deference to a patient’s wishes, or more lati22 tude in determining a patient’s wishes.’’. 

23 (b) MEDICAID.—Section 1902(w) of the Social Secu24 rity Act (42 U.S.C. 1396a(w)) is amended— 

25 (1) in paragraph (1)— 


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1 (A) in subparagraph (B)— 

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

3 medical record’’ and inserting ‘‘in a promi4 nent part of the individual’s current med5 ical record’’; and 

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

7 the individual, to include the content of 

8 such advance directive in a prominent part 

9 of such record’’ before the semicolon at the 

10 end; 

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

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

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

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

15 (D) by inserting after subparagraph (E) 

16 the following new subparagraph: 

17 ‘‘(F) to provide each individual with the oppor18 tunity to discuss issues relating to the information 

19 provided to that individual pursuant to subpara20 graph (A) with an appropriately trained profes21 sional.’’; 

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

23 and inserting ‘‘an’’; and 

24 (3) by adding at the end the following para25 graph: 


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

2 of the State in which such advance directive is presented 

3 by an adult individual to a provider or organization shall 

4 be given the same effect by that provider or organization 

5 as an advance directive validly executed under the law of 

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

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

8 also include actual knowledge of instructions made while 

9 an individual was able to express the wishes of such indi10 vidual with regard to health care. 

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

12 knowledge’ means the possession of information of an indi13 vidual’s wishes communicated to the health care provider 

14 orally or in writing by the individual, the individual’s med15 ical power of attorney representative, the individual’s 

16 health care surrogate, or other individuals resulting in the 

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

18 Other forms of imputed knowledge are not actual knowl19 edge. 

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

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

22 such provisions. The provisions of this paragraph shall not 

23 preempt any State law that provides for greater port24 ability, more deference to a patient’s wishes, or more lati25 tude in determining a patient’s wishes.’’. 


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

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

3 (1) by redesignating subparagraphs (E) 

4 through (L) as subparagraphs (D) through (M), re5 spectively; and 

6 (2) by inserting after subparagraph (D) the fol7 lowing: 

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

9 directives).’’. 

10 (d) STUDY AND REPORT REGARDING IMPLEMENTA11 TION.— 

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

13 study regarding the implementation of the amend14 ments made by subsections (a) and (b). 

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

16 the date of enactment of this Act, the Secretary 

17 shall submit to Congress a report on the study con18 ducted under paragraph (1), together with rec19 ommendations for such legislation and administra20 tive actions as the Secretary considers appropriate. 

21 (e) EFFECTIVE DATES.— 

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

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

24 (c) shall apply to provider agreements and contracts 

25 entered into, renewed, or extended under title XVIII 


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

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

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

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

5 seq.), on or after such date as the Secretary speci6 fies, but in no case may such date be later than 1 

7 year after the date of enactment of this Act. 

8 (2) EXTENSION OF EFFECTIVE DATE FOR

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

10 plan under title XIX of the Social Security Act or 

11 a State child health plan under title XXI of such 

12 Act which the Secretary determines requires State 

13 legislation in order for the plan to meet the addi14 tional requirements imposed by the amendments 

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

16 not be regarded as failing to comply with the re17 quirements of such title solely on the basis of its 

18 failure to meet these additional requirements before 

19 the first day of the first calendar quarter beginning 

20 after the close of the first regular session of the 

21 State legislature that begins after the date of enact22 ment of this Act. For purposes of the previous sen23 tence, in the case of a State that has a 2-year legis24 lative session, each year of the session is considered 


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1 to be a separate regular session of the State legisla2 ture. 

3 SEC. 132. STATE ADVANCE DIRECTIVE REGISTRIES; DRIV4 ER’S LICENSE ADVANCE DIRECTIVE NOTA5 TION. 

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

7 (42 U.S.C. 280g) is amended— 

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

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

10 399S; 

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

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

13 399T; and 

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

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

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

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

18 means a secure, electronic database that— 

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

20 a State; and 

21 ‘‘(2) stores advance directive documents and 

22 makes such documents accessible to medical service 

23 providers in accordance with Federal and State pri24 vacy laws. 


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

2 the Secretary, acting through the Director of the Centers 

3 for Disease Control and Prevention, shall award grants 

4 on a competitive basis to eligible entities to establish and 

5 operate, directly or indirectly (by competitive grant or 

6 competitive contract), State advance directive registries. 

7 ‘‘(c) ELIGIBLE ENTITIES.— 

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

9 grant under this section, an entity shall— 

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

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

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

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

14 operation of a State advance directive reg15 istry; and 

16 ‘‘(ii) such other information as the Di17 rector may require. 

18 ‘‘(2) NO REQUIREMENT OF NOTATION MECHA19 NISM.—The Secretary shall not require that an enti20 ty establish and operate a driver’s license advance 

21 directive notation mechanism for State residents 

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

23 under this section. 

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

25 entity receives an award under this section, such entity 


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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 registry. 

4 ‘‘(e) AUTHORIZATION.—There is authorized to be ap5 propriated to carry out this section $20,000,000 for fiscal 

6 year 2010 and each fiscal year thereafter. 

7 ‘‘SEC. 399V. DRIVER’S LICENSE ADVANCE DIRECTIVE NOTA8 TION. 

9 ‘‘(a) IN GENERAL.—Beginning July 1, 2010, the Sec10 retary, acting through the Director of the Centers for Dis11 ease Control and Prevention, shall award grants on a com12 petitive basis to States to establish and operate a mecha13 nism for a State resident with a driver’s license to include 

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

15 resident on such license. 

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

17 under this section, a State shall— 

18 ‘‘(1) establish and operate a State advance di19 rective registry under section 399U; and 

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

21 such time, in such manner, and containing— 

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

23 how the State will— 


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1 ‘‘(i) disseminate information about ad2 vance directives at the time of driver’s li3 cense application or renewal; 

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

5 driver’s license to include a notice of the 

6 existence of an advance directive for such 

7 resident on such license in a manner con8 sistent with the notice on such a license in9 dicating a driver’s intent to be an organ 

10 donor; and 

11 ‘‘(iii) coordinate with the State de12 partment of health to ensure that, if a 

13 State resident has an advance directive no14 tice on his or her driver’s license, the exist15 ence of such advance directive is included 

16 in the State registry established under sec17 tion 399U; and 

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

19 may require. 

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

21 State receives an award under this section, such State 

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

23 of the funds received pursuant to such award, including 

24 the number of State residents served through the mecha25 nism. 


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1 ‘‘(d) AUTHORIZATION.—There is authorized to be ap2 propriated to carry out this section $50,000,000 for fiscal 

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

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

5 NATIONAL ADVANCE DIRECTIVE REGISTRY. 

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

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

8 registry for advance directives, taking into consideration 

9 the constraints created by the privacy provisions enacted 

10 as a result of the Health Insurance Portability and Ac11 countability Act of 1996 (Public Law 104–191). 

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

13 date of enactment of this Act, the Comptroller General 

14 of the United States shall submit to Congress a report 

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

16 recommendations for such legislation and administrative 

17 action as the Comptroller General of the United States 

18 determines to be appropriate. 

19 Subtitle C—National Uniform 

20 Policy on Advance Care Planning 

21 SEC. 141. STUDY AND REPORT BY THE SECRETARY RE22 GARDING THE ESTABLISHMENT AND IMPLE23 MENTATION OF A NATIONAL UNIFORM POL24 ICY ON ADVANCE DIRECTIVES. 

25 (a) STUDY.— 


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

2 through the Office of the Assistant Secretary for 

3 Planning and Evaluation, shall conduct a thorough 

4 study of all matters relating to the establishment 

5 and implementation of a national uniform policy on 

6 advance directives for individuals receiving items and 

7 services under titles XVIII, XIX, or XXI of the So8 cial Security Act (42 U.S.C. 1395 et seq.; 1396 et 

9 seq.; 1397aa et seq.). 

10 (2) MATTERS STUDIED.—The matters studied 

11 by the Secretary under paragraph (1) shall include 

12 issues concerning— 

13 (A) family satisfaction that a patient’s 

14 wishes, as stated in the patient’s advance direc15 tive, were carried out; 

16 (B) the portability of advance directives, 

17 including cases involving the transfer of an in18 dividual from one health care setting to an19 other; 

20 (C) immunity from civil liability and crimi21 nal responsibility for health care providers that 

22 follow the instructions in an individual’s ad23 vance directive that was validly executed in, and 

24 consistent with the laws of, the State in which 

25 it was executed; 


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1 (D) conditions under which an advance di2 rective is operative; 

3 (E) revocation of an advance directive by 

4 an individual; 

5 (F) the criteria used by States for deter6 mining that an individual has a terminal condi7 tion; 

8 (G) surrogate decisionmaking regarding 

9 end-of-life care; 

10 (H) the provision of adequate palliative 

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

12 pain management; 

13 (I) adequate and timely referrals to hos14 pice care programs; and 

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

16 and their families. 

17 (3) PALLIATIVE CARE.—For purposes of para18 graph (2)(H), the term ‘‘palliative care’’ means 

19 interdisciplinary care for individuals with a life20 threatening illness or injury relating to pain and 

21 symptom management and psychological, social, and 

22 spiritual needs and that seeks to improve the quality 

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

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

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1 retary shall submit to Congress a report on the study con2 ducted under subsection (a), together with recommenda3 tions for such legislation and administrative actions as the 

4 Secretary considers appropriate. 

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

6 developing the report under this section, the Secretary 

7 shall consult with the Uniform Law Commissioners, and 

8 other interested parties. 

9 TITLE II—COMPASSIONATE 

10 CARE 

11 Subtitle A—Workforce 

12 Development 

13 PART I—EDUCATION AND TRAINING 

14 SEC. 201. NATIONAL GERIATRIC AND PALLIATIVE CARE 

15 SERVICES CORPS. 

16 Section 331 of the Public Health Service Act (42 

17 U.S.C. 254d) is amended— 

18 (1) by redesignating subsection (j) as sub19 section (k); and 

20 (2) by inserting after subsection (i), the fol21 lowing: 

22 ‘‘(j) NATIONAL GERIATRIC AND PALLIATIVE CARE

23 SERVICES CORPS.— 

24 ‘‘(1) ESTABLISHMENT.—Not later than Janu25 ary 1, 2012, the Secretary shall establish within the 


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1 National Health Service Corps a National Geriatric 

2 and Palliative Care Services Corps (referred to in 

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

4 of— 

5 ‘‘(A) such officers of the Regular and Re6 serve Corps of the Service as the Secretary may 

7 designate; 

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

9 States as the Secretary may appoint; and 

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

11 employees of the United States. 

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

13 the Secretary to provide geriatric and palliative care 

14 services within health professional shortage areas. 

15 ‘‘(3) APPLICATION OF PROVISIONS.—The loan16 forgiveness, scholarship, and direct financial incen17 tives programs provided for under this section shall 

18 apply to physicians, nurses, and other health profes19 sionals (as identified by the Secretary) with respect 

20 to the training necessary to enable such individuals 

21 to become geriatric or palliative care specialists and 

22 provide geriatric and palliative care services in 

23 health professional shortage areas. 

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

25 to the date on which the Secretary establishes the 


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1 Corps under paragraph (1), the Secretary shall sub2 mit to Congress a report concerning the organization 

3 of the Corps, the application process for membership 

4 in the Corps, and the funding necessary for the 

5 Corps (targeted by profession and by specializa6 tion).’’. 

7 SEC. 202. EXEMPTION OF PALLIATIVE MEDICINE FELLOW8 SHIP TRAINING FROM MEDICARE GRADUATE 

9 MEDICAL EDUCATION CAPS. 

10 (a) DIRECT GRADUATE MEDICAL EDUCATION.—Sec11 tion 1886(h)(4)(F) of the Social Security Act (42 U.S.C. 

12 1395ww(h)(4)(F)) is amended— 

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

14 after ‘‘subject to’’; and 

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

16 clause: 

17 ‘‘(iii) INCREASE ALLOWED FOR PAL18 LIATIVE MEDICINE FELLOWSHIP TRAIN19 ING.—For cost reporting periods beginning 

20 on or after January 1, 2011, in applying 

21 clause (i), there shall not be taken into ac22 count full-time equivalent residents in the 

23 field of allopathic or osteopathic medicine 

24 who are in palliative medicine fellowship 

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1 tion Council for Graduate Medical Edu2 cation.’’. 

3 (b) INDIRECT MEDICAL EDUCATION.—Section 

4 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 

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

6 following new clause: 

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

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

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

10 of such subsection.’’. 

11 SEC. 203. MEDICAL SCHOOL CURRICULA. 

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

13 with the Association of American Medical Colleges, shall 

14 establish guidelines for the imposition by medical schools 

15 of a minimum amount of end-of-life training as a require16 ment for obtaining a Doctor of Medicine degree in the field 

17 of allopathic or osteopathic medicine. 

18 (b) TRAINING.—Under the guidelines established 

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

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

21 and their loved ones with advance care planning; 

22 (2) with respect to students and trainees who 

23 will work with children, specialized pediatric train24 ing; 


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

2 services and supports, including palliative care and 

3 hospice; 

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

5 with dying patients and their loved ones; and 

6 (5) medical and legal issues training. 

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

8 the Secretary shall disseminate the guidelines established 

9 under subsection (a) to medical schools. 

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

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

12 assistance shall be required to implement the guidelines 

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

14 Secretary determines is not implementing such guidelines 

15 shall not be eligible for Federal assistance. 

16 Subtitle B—Coverage Under 

17 Medicare, Medicaid, and CHIP 

18 PART I—COVERAGE OF ADVANCE CARE 

19 PLANNING 

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

21 (a) MEDICARE.— 

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

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

24 (A) in subsection (s)(2)— 


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

2 subparagraph (DD); 

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

4 subparagraph (EE); and 

5 (iii) by adding at the end the fol6 lowing new subparagraph: 

7 ‘‘(FF) advance care planning consultation 

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

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

10 subsection: 

11 ‘‘Advance Care Planning Consultation 

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

13 term ‘advance care planning consultation’ means a con14 sultation between the individual and a practitioner de15 scribed in paragraph (2) regarding advance care planning, 

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

17 the individual involved has not had such a consultation 

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

19 following: 

20 ‘‘(A) An explanation by the practitioner of ad21 vance care planning, including key questions and 

22 considerations, important steps, and suggested peo23 ple to talk to. 


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1 ‘‘(B) An explanation by the practitioner of ad2 vance directives, including living wills and durable 

3 powers of attorney, and their uses. 

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

5 role and responsibilities of a health care proxy. 

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

7 of national and State-specific resources to assist con8 sumers and their families with advance care plan9 ning, including the national toll-free hotline, the ad10 vance care planning clearinghouses, and State legal 

11 service organizations (including those funded 

12 through the Older Americans Act). 

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

14 continuum of end-of-life services and supports avail15 able, including palliative care and hospice, and bene16 fits for such services and supports that are available 

17 under this title. 

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

19 orders regarding life sustaining treatment or similar 

20 orders, which shall include— 

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

22 such an order is beneficial to the individual and 

23 the individual’s family and the reasons why 

24 such an order should be updated periodically as 

25 the health of the individual changes; 


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1 ‘‘(II) the information needed for an indi2 vidual or legal surrogate to make informed deci3 sions regarding the completion of such an 

4 order; and 

5 ‘‘(III) the identification of resources that 

6 an individual may use to determine the require7 ments of the State in which such individual re8 sides so that the treatment wishes of that indi9 vidual will be carried out if the individual is un10 able to communicate those wishes, including re11 quirements regarding the designation of a sur12 rogate decision maker (also known as a health 

13 care proxy). 

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

15 for explanations under clause (i) to consultations 

16 furnished in States, localities, or other geographic 

17 areas in which orders described in such clause have 

18 been widely adopted. 

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

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

21 (r)(1)); and 

22 ‘‘(B) a nurse practitioner or physician’s assist23 ant who has the authority under State law to sign 

24 orders for life sustaining treatments. 


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

2 under subsection (ww), including any related discussion 

3 during such examination, shall not be considered an ad4 vance care planning consultation for purposes of applying 

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

6 ‘‘(B) An advance care planning consultation with re7 spect to an individual shall be conducted more frequently 

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

9 change in the health condition of the individual, including 

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

11 life-threatening or terminal diagnosis or life-threatening 

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

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

14 a hospice program. 

15 ‘‘(4) A consultation under this subsection may in16 clude the formulation of an order regarding life sustaining 

17 treatment or a similar order. 

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

19 regarding life sustaining treatment’ means, with respect 

20 to an individual, an actionable medical order relating to 

21 the treatment of that individual that— 

22 ‘‘(i) is signed and dated by a physician (as de23 fined in subsection (r)(1)) or another health care 

24 professional (as specified by the Secretary and who 

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1 thority under State law in signing such an order) 

2 and is in a form that permits it to stay with the pa3 tient and be followed by health care professionals 

4 and providers across the continuum of care, includ5 ing home care, hospice, long-term care, community 

6 and assisted living residences, skilled nursing facili7 ties, inpatient rehabilitation facilities, hospitals, and 

8 emergency medical services; 

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

10 preferences regarding life sustaining treatment, in11 cluding an indication of the treatment and care de12 sired by the individual; 

13 ‘‘(iii) is uniquely identifiable and standardized 

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

15 by the Secretary); 

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

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

18 defined in section 1866(f)(3)) if executed by the in19 dividual. 

20 ‘‘(B) The level of treatment indicated under subpara21 graph (A)(ii) may range from an indication for full treat22 ment to an indication to limit some or all or specified 

23 interventions. Such indicated levels of treatment may in24 clude indications respecting, among other items— 


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

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

3 pulmonary problems; 

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

5 to a hospital or remaining at the current care set6 ting; 

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

8 ‘‘(iv) the use of artificially administered nutri9 tion and hydration.’’. 

10 (2) PAYMENT.—Section 1848(j)(3) of the So11 cial Security Act (42 U.S.C. 1395w–4(j)(3)) is 

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

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

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

15 is amended— 

16 (A) in paragraph (1)— 

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

18 ‘‘and’’ at the end; 

19 (ii) in subparagraph (O) by striking 

20 the semicolon at the end and inserting ‘‘, 

21 and’’; and 

22 (iii) by adding at the end the fol23 lowing new subparagraph: 

24 ‘‘(P) in the case of advance care planning con25 sultations (as defined in section 1861(hhh)(1)), 


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1 which are performed more frequently than is covered 

2 under such section;’’; and 

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

4 and inserting ‘‘(K), or (P)’’. 

5 (4) EFFECTIVE DATE.—The amendments made 

6 by this subsection shall apply to consultations fur7 nished on or after January 1, 2011. 

8 (b) MEDICAID.— 

9 (1) MANDATORY BENEFIT.—Section 

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

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

12 preceding clause (i) by striking ‘‘and (21)’’ and in13 serting ‘‘, (21), and (28)’’. 

14 (2) MEDICAL ASSISTANCE.—Section 1905 of 

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

16 (A) in subsection (a)— 

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

18 ‘‘and’’ at the end; 

19 (ii) by redesignating paragraph (28) 

20 as paragraph (29); and 

21 (iii) by inserting after paragraph (27) 

22 the following new paragraph: 

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

24 defined in subsection (y));’’; and 

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


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

2 ‘advance care planning consultation’ means a consultation 

3 between the individual and a practitioner described in 

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

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

6 a consultation within the last 5 years. Such consultation 

7 shall include the following: 

8 ‘‘(A) An explanation by the practitioner of ad9 vance care planning, including key questions and 

10 considerations, important steps, and suggested peo11 ple to talk to. 

12 ‘‘(B) An explanation by the practitioner of ad13 vance directives, including living wills and durable 

14 powers of attorney, and their uses. 

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

16 role and responsibilities of a health care proxy. 

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

18 of national and State-specific resources to assist con19 sumers and their families with advance care plan20 ning, including the national toll-free hotline, the ad21 vance care planning clearinghouses, and State legal 

22 service organizations (including those funded 

23 through the Older Americans Act). 

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

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1 able, including palliative care and hospice, and bene2 fits for such services and supports that are available 

3 under this title. 

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

5 orders for life sustaining treatments or similar or6 ders, which shall include— 

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

8 such an order is beneficial to the individual and 

9 the individual’s family and the reasons why 

10 such an order should be updated periodically as 

11 the health of the individual changes; 

12 ‘‘(II) the information needed for an indi13 vidual or legal surrogate to make informed deci14 sions regarding the completion of such an 

15 order; and 

16 ‘‘(III) the identification of resources that 

17 an individual may use to determine the require18 ments of the State in which such individual re19 sides so that the treatment wishes of that indi20 vidual will be carried out if the individual is un21 able to communicate those wishes, including re22 quirements regarding the designation of a sur23 rogate decision maker (also known as a health 

24 care proxy). 


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

2 for explanations under clause (i) to consultations 

3 furnished in States, localities, or other geographic 

4 areas in which orders described in such clause have 

5 been widely adopted. 

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

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

8 1861(r)(1)); and 

9 ‘‘(B) a nurse practitioner or physician’s assist10 ant who has the authority under State law to sign 

11 orders for life sustaining treatments. 

12 ‘‘(3) An advance care planning consultation with re13 spect to an individual shall be conducted more frequently 

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

15 change in the health condition of the individual including 

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

17 life-threatening or terminal diagnosis or life-threatening 

18 injury, or upon admission to a nursing facility, a long19 term care facility (as defined by the Secretary), or a hos20 pice program. 

21 ‘‘(4) A consultation under this subsection may in22 clude the formulation of an order regarding life sustaining 

23 treatment or a similar order. 


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

2 regarding life sustaining treatment’ has the meaning given 

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

4 (c) CHIP.— 

5 (1) CHILD HEALTH ASSISTANCE.—Section 

6 2110(a) of the Social Security Act (42 U.S.C. 

7 1397jj) is amended— 

8 (A) by redesignating paragraph (28) as 

9 paragraph (29); and 

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

11 following: 

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

13 defined in section 1905(y)).’’. 

14 (2) MANDATORY COVERAGE.— 

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

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

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

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

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

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

21 end the following: 

22 ‘‘(9) END-OF-LIFE CARE.—The child health as23 sistance provided to a targeted low-income child 

24 shall include coverage of advance care planning con25 sultations (as defined in section 1905(y) and at the 


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1 same payment rate as the rate that would apply to 

2 such a consultation under the State plan under title 

3 XIX).’’. 

4 (B) CONFORMING AMENDMENT.—Section 

5 2102(a)(7)(B) of such Act (42 U.S.C. 

6 1397bb(a)(7)(B)) is amended by striking ‘‘sec7 tion 2103(c)(5)’’ and inserting ‘‘paragraphs (5) 

8 and (9) of section 2103(c)’’. 

9 (d) DEFINITION OF ADVANCE DIRECTIVE UNDER

10 MEDICARE, MEDICAID, AND CHIP.— 

11 (1) MEDICARE.—Section 1866(f)(3) of the So12 cial Security Act (42 U.S.C. 1395cc(f)(3)) is amend13 ed by striking ‘‘means’’ and all that follows through 

14 the period and inserting ‘‘means a living will, med15 ical directive, health care power of attorney, durable 

16 power of attorney, or other written statement by a 

17 competent individual that is recognized under State 

18 law and indicates the individual’s wishes regarding 

19 medical treatment in the event of future incom20 petence. Such term includes an advance health care 

21 directive and a health care directive recognized 

22 under State law.’’. 

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

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

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


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1 period and inserting ‘‘means a living will, medical di2 rective, health care power of attorney, durable power 

3 of attorney, or other written statement by a com4 petent individual that is recognized under State law 

5 and indicates the individual’s wishes regarding med6 ical treatment in the event of future incompetence. 

7 Such term includes an advance health care directive 

8 and a health care directive recognized under State 

9 law.’’. 

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

11 this section take effect January 1, 2010. 

12 PART II—HOSPICE 

13 SEC. 221. ADOPTION OF MEDPAC HOSPICE PAYMENT METH14 ODOLOGY RECOMMENDATIONS. 

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

16 1395f(i)) is amended by adding at the end the following 

17 new paragraph: 

18 ‘‘(6)(A) The Secretary shall conduct an evalua19 tion of the recommendations of the Medicare Pay20 ment Commission for reforming the hospice care 

21 benefit under this title that are contained in chapter 

22 6 of the Commission’s report entitled ‘Report to 

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

24 including the impact that such recommendations if 

25 implemented would have on access to care and the 


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1 quality of care. In conducting such evaluation, the 

2 Secretary shall take into account data collected in 

3 accordance with section 263(b) of the Advance Plan4 ning and Compassionate Care Act of 2009. 

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

6 conducted under subparagraph (A), the Secretary 

7 shall make appropriate refinements to the rec8 ommendations described in subparagraph (A). Such 

9 refinements shall take into account— 

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

11 longer that average lengths of stay; 

12 ‘‘(ii) the impact on populations with short13 er that average lengths of stay; and 

14 ‘‘(iii) the utilization patterns of hospice 

15 providers in underserved areas, including rural 

16 hospices. 

17 ‘‘(C) Not later than January 1, 2013, the Sec18 retary shall submit to Congress a report that con19 tains a detailed description of— 

20 ‘‘(i) the refinements determined appro21 priate by the Secretary under subparagraph 

22 (B); 

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

24 implement through regulation under this title 

25 pursuant to subparagraph (D); and 


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1 ‘‘(iii) the revisions that the Secretary de2 termines require additional legislative action by 

3 Congress. 

4 ‘‘(D)(i) The Secretary shall implement the rec5 ommendations described in subparagraph (A), as re6 fined under subparagraph (B). 

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

8 of such recommendations shall apply to hospice care 

9 furnished on or after January 1, 2014. 

10 ‘‘(iii) The Secretary shall establish an appro11 priate transition to the implementation of such rec12 ommendations. 

13 ‘‘(E) For purposes of carrying out the provi14 sions of this paragraph, the Secretary shall provide 

15 for the transfer, from the Federal Hospital Insur16 ance Trust Fund under section 1817, of such sums 

17 as may be necessary to the Centers for Medicare & 

18 Medicaid Services Program Management Account.’’. 

19 SEC. 222. REMOVING HOSPICE INPATIENT DAYS IN SET20 TING PER DIEM RATES FOR CRITICAL AC21 CESS HOSPITALS. 

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

23 1395f(l)), as amended by section 4102(b)(2) of the 

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

25 at the end the following new paragraph: 


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

2 after January 1, 2011, the Secretary shall remove 

3 Medicare-certified hospice inpatient days from the 

4 calculation of per diem rates for inpatient critical ac5 cess hospital services.’’. 

6 SEC. 223. HOSPICE PAYMENTS FOR DUAL ELIGIBLE INDI7 VIDUALS RESIDING IN LONG-TERM CARE FA8 CILITIES. 

9 (a) IN GENERAL.—Section 1888 of the Social Secu10 rity Act (42 U.S.C. 1395yy) is amended by adding at the 

11 end the following new subsection: 

12 ‘‘(f) PAYMENTS FOR DUAL ELIGIBLE INDIVIDUALS

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

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

15 the Secretary, acting through the Administrator of the 

16 Centers for Medicare & Medicaid Services, shall establish 

17 procedures under which payments for room and board 

18 under the State Medicaid plan with respect to an applica19 ble individual are made directly to the long-term care facil20 ity (as defined by the Secretary for purposes of title XIX) 

21 the individual is a resident of. For purposes of the pre22 ceding sentence, the term ‘applicable individual’ means an 

23 individual who is entitled to or enrolled for benefits under 

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


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1 for medical assistance for hospice care under a State plan 

2 under title XIX.’’. 

3 (b) STATE PLAN REQUIREMENT.— 

4 (1) IN GENERAL.—Section 1902(a) of the So5 cial Security Act (42 U.S.C. 1396a(a)) is amend6 ed— 

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

8 at the end; 

9 (B) in paragraph (73), by striking the pe10 riod at the end and inserting ‘‘; and’’; and 

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

12 following new paragraph: 

13 ‘‘(74) provide that the State will make pay14 ments for room and board with respect to applicable 

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

16 (2) EFFECTIVE DATE.— 

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

18 subparagraph (B), the amendments made by 

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

20 (B) EXTENSION OF EFFECTIVE DATE FOR

21 STATE LAW AMENDMENT.—In the case of a 

22 State plan under title XIX of the Social Secu23 rity Act (42 U.S.C. 1396 et seq.) which the 

24 Secretary determines requires State legislation 

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1 quirements imposed by the amendments made 

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

3 regarded as failing to comply with the require4 ments of such title solely on the basis of its fail5 ure to meet these additional requirements be6 fore the first day of the first calendar quarter 

7 beginning after the close of the first regular 

8 session of the State legislature that begins after 

9 the date of enactment of this Act. For purposes 

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

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

12 of the session is considered to be a separate 

13 regular session of the State legislature. 

14 SEC. 224. DELINEATION OF RESPECTIVE CARE RESPON15 SIBILITIES OF HOSPICE PROGRAMS AND 

16 LONG-TERM CARE FACILITIES. 

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

18 1395yy), as amended by section 223(a), is amended by 

19 adding at the end the following new subsection: 

20 ‘‘(g) DELINEATION OF RESPECTIVE CARE RESPON21 SIBILITIES OF HOSPICE PROGRAMS AND LONG-TERM

22 CARE FACILITIES.—Not later than July 1, 2011, the Sec23 retary, acting through the Administrator of the Centers 

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1 grams and long-term care facilities (as defined by the Sec2 retary for purposes of title XIX) with respect to individ3 uals residing in such facilities who are furnished hospice 

4 care.’’. 

5 SEC. 225. ADOPTION OF MEDPAC HOSPICE PROGRAM ELI6 GIBILITY CERTIFICATION AND RECERTIFI7 CATION RECOMMENDATIONS. 

8 In accordance with the recommendations of the Medi9 care Payment Advisory Commission contained in the 

10 March 2009 report entitled ‘‘Report to Congress: Medi11 care Payment Policy’’, section 1814(a)(7) of the Social Se12 curity Act (42 U.S.C. 1395f(a)(7)) is amended— 

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

14 the end; and 

15 (2) by adding at the end the following new sub16 paragraph: 

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

18 ‘‘(i) a hospice physician or advance 

19 practice nurse visits the individual to de20 termine continued eligibility of the indi21 vidual for hospice care prior to the 180th 

22 day recertification and each subsequent re23 certification under subparagraph (A)(ii) 

24 and attests that such visit took place (in 

25 accordance with procedures established by 


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1 the Secretary, in consultation with the Ad2 ministrator of the Centers for Medicare & 

3 Medicaid Services); and 

4 ‘‘(ii) any certification or recertification 

5 under subparagraph (A) includes a brief 

6 narrative describing the clinical basis for 

7 the individual’s prognosis (in accordance 

8 with procedures established by the Sec9 retary, in consultation with the Adminis10 trator of the Centers for Medicare & Med11 icaid Services); and’’. 

12 SEC. 226. CONCURRENT CARE FOR CHILDREN. 

13 (a) PERMITTING MEDICARE HOSPICE BENE14 FICIARIES 18 YEARS OF AGE OR YOUNGER TO RECEIVE

15 CURATIVE CARE.— 

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

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

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

19 ‘‘(subject to the second sentence of subsection 

20 (d)(2)(A))’’ after ‘‘in lieu of certain other bene21 fits’’; and 

22 (B) in subsection (d)— 

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

24 subject to the second sentence of para25 graph (2)(A),’’ after ‘‘instead’’; and 


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

2 the end the following new sentence: 

3 ‘‘Clause (ii)(I) shall not apply to an indi4 vidual who is 18 years of age or younger.’’ 

5 (2) CONFORMING AMENDMENT.—Section 

6 1862(a)(1)(C) of the Social Security Act (42 U.S.C. 

7 1395y(a)(1)(C)) is amended inserting ‘‘subject to 

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

9 ‘‘hospice care,’’. 

10 (b) APPLICATION TO MEDICAID AND CHIP.— 

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

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

13 amended by inserting ‘‘(subject, in the case of an in14 dividual who is a child, to the second sentence of 

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

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

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

18 by inserting ‘‘(concurrent, in the case of an indi19 vidual who is a child, with care related to the treat20 ment of the individual’s condition with respect to 

21 which a diagnosis of terminal illness has been 

22 made)’’ after ‘‘hospice care’’. 

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

24 this section shall apply to items and services furnished on 

25 or after January 1, 2011. 


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1 SEC. 227. MAKING HOSPICE A REQUIRED BENEFIT UNDER 

2 MEDICAID AND CHIP. 

3 (a) MANDATORY BENEFIT.— 

4 (1) MEDICAID.— 

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

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

7 1396a(a)(10)(A)), as amended by section 

8 211(b)(1), is amended in the matter preceding 

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

10 (B) CONFORMING AMENDMENT.—Section 

11 1902(a)(10)(C) of such Act (42 U.S.C. 

12 1396a(a)(10)(C)) is amended— 

13 (i) in clause (iii)— 

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

15 ‘‘and hospice care’’ after ‘‘ambulatory 

16 services’’; and 

17 (II) in subclause (II), by insert18 ing ‘‘and hospice care’’ after ‘‘delivery 

19 services’’; and 

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

21 (18)’’ after ‘‘(17)’’. 

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

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

24 211(c)(2)(A), is amended by inserting ‘‘and hospice 

25 care’’ before the period. 


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1 (b) EFFECTIVE DATE.—The amendments made sub2 section (a) take effect on January 1, 2011. 

3 SEC. 228. MEDICARE HOSPICE PAYMENT MODEL DEM4 ONSTRATION PROJECTS. 

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

6 the Secretary, acting through the Administrator of the 

7 Centers for Medicare & Medicaid Services and the Direc8 tor of the Agency for Healthcare Research and Quality, 

9 shall conduct demonstration projects to examine ways to 

10 improve how the Medicare hospice care benefit predicts 

11 disease trajectory. Projects shall include the following 

12 models: 

13 (1) Models that better and more appropriately 

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

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

16 qualify for hospice care under the Medicare hospice 

17 eligibility criteria. 

18 (2) Models that better and more appropriately 

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

20 hospice but still need palliative care. 

21 (3) Any other models determined appropriate 

22 by the Secretary. 

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

24 compliance of such requirements of titles XI and XVIII 

25 of the Social Security Act as the Secretary determines necVerDate Nov 24 2008 03:55 Jun 20, 2009 Jkt 079200 PO 00000 Frm 00073 Fmt 6652 Sfmt 6201 E:\BILLS\H2911.IH H2911

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1 essary to conduct the demonstration projects under this 

2 section. 

3 (c) REPORTS.—The Secretary shall submit to Con4 gress periodic reports on the demonstration projects con5 ducted under this section. 

6 SEC. 229. MEDPAC STUDIES AND REPORTS. 

7 (a) STUDY AND REPORT REGARDING AN ALTER8 NATIVE PAYMENT METHODOLOGY FOR HOSPICE CARE

9 UNDER THE MEDICARE PROGRAM.— 

10 (1) STUDY.—The Medicare Payment Advisory 

11 Commission (in this section referred to as the ‘‘Com12 mission’’) shall conduct a study on the establishment 

13 of a reimbursement system for hospice care fur14 nished under the Medicare program that is based on 

15 diagnoses. In conducting such study, the Commis16 sion shall use data collected under new provider data 

17 requirements. Such study shall include an analysis 

18 of the following: 

19 (A) Whether such a reimbursement system 

20 better meets patient needs and better cor21 responds with provider resource expenditures 

22 than the current system. 

23 (B) Whether such a reimbursement system 

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1 ardization of care toward best practices and di2 agnoses-specific clinical pathways in hospice. 

3 (C) Whether such a reimbursement system 

4 could address concerns about the blanket 6- 

5 month terminal prognosis requirement in hos6 pice. 

7 (D) Whether such a reimbursement system 

8 is more cost effective than the current system. 

9 (E) Any other areas determined appro10 priate by the Commission. 

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 (b) STUDY AND REPORT REGARDING RURAL HOS18 PICE TRANSPORTATION COSTS UNDER THE MEDICARE

19 PROGRAM.— 

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

21 study on rural Medicare hospice transportation mile22 age to determine potential Medicare reimbursement 

23 changes to account for potential higher costs. 

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

25 the Commission shall submit to Congress a report 


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1 on the study conducted under subsection (a) to2 gether with recommendations for such legislation 

3 and administrative action as the Commission deter4 mines appropriate. 

5 (c) EVALUATION OF REIMBURSEMENT DISINCEN6 TIVES TO ELECT MEDICARE HOSPICE WITHIN THE

7 MEDICARE SKILLED NURSING FACILITY BENEFIT.— 

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

9 study to determine potential Medicare reimburse10 ment changes to remove Medicare reimbursement 

11 disincentives for patients in a skilled nursing facility 

12 who want to elect hospice. 

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

14 the Commission shall submit to Congress a report 

15 on the study conducted under subsection (a) to16 gether with recommendations for such legislation 

17 and administrative action as the Commission deter18 mines appropriate. 

19 SEC. 230. HHS EVALUATIONS. 

20 (a) EVALUATION OF ACCESS TO HOSPICE AND HOS21 PITAL-BASED PALLIATIVE CARE.— 

22 (1) EVALUATION.—The Secretary, acting 

23 through the Administrator of the Health Resources 

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1 served by hospice and hospital-based palliative care 

2 to identify potential barriers to access. 

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

4 2012, the Secretary shall report to Congress, on the 

5 evaluation conducted under subsection (a) together 

6 with recommendations for such legislation and ad7 ministrative action as the Secretary determines ap8 propriate to address barriers to access to hospice 

9 and hospital-based palliative care. 

10 (b) EVALUATION OF AWARENESS AND USE OF HOS11 PICE RESPITE CARE UNDER MEDICARE, MEDICAID, AND

12 CHIP.— 

13 (1) EVALUATION.—The Secretary, acting 

14 through the Director of the Centers for Medicare & 

15 Medicaid Services, shall evaluate the awareness and 

16 use of hospice respite care by informal caregivers of 

17 beneficiaries under Medicare, Medicaid, and CHIP. 

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

19 2010, the Secretary shall report to Congress, on the 

20 evaluation conducted under subsection (a) together 

21 with recommendations for such legislation and ad22 ministrative action as the Secretary determines ap23 propriate to increase awareness or use of hospice 

24 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 

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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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