I 

111TH CONGRESS 

1ST SESSION H. R. 3172 

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

illness care management services for Medicare beneficiaries, and for 

other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JULY 10, 2009 

Ms. BALDWIN (for herself and Mr. TANNER) introduced the following bill; 

which was referred to the Committee on Energy and Commerce, and in 

addition to the Committee on Ways and Means, 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 amend title XVIII of the Social Security Act to provide 

for advanced illness care management services for Medicare beneficiaries, and for other purposes. 

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

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

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

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

7 this Act is as follows: 

Sec. 1. Short title; table of contents. 

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

services. 

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

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

Sec. 5. Senior Navigation Advisory Board. 

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

Medicare beneficiaries with information on advance directives 

and other end-of-life planning tools. 

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

directives. 

Sec. 8. Additional requirements for facilities. 

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

care. 

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

care. 

Sec. 11. Discharge checklist pilot program. 

Sec. 12. Office of Medicare/Medicaid Integration. 

Sec. 13. Web-based materials and grants. 

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

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

this Act. 

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

4 (a) MEDICARE COVERAGE OF ADVANCED ILLNESS

5 CARE MANAGEMENT SERVICES.— 

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

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

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

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

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

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

2 Security Act (42 U.S.C. 1395x) is amended by add3 ing at the end the following new subsection: 

4 ‘‘Advanced Illness Care Management Services 

5 ‘‘(hhh)(1) The term ‘advanced illness care manage6 ment services’ means the following services furnished to 

7 an individual by a hospice program, as defined in sub8 section (dd)(2): 

9 ‘‘(A) Palliative care consultation services. 

10 ‘‘(B) Care planning services. 

11 ‘‘(C) Counseling of individual and family mem12 bers. 

13 ‘‘(D) Discussions regarding the availability of 

14 supportive services (including information on ad15 vance care planning). 

16 ‘‘(E) Patient-centered care. 

17 ‘‘(F) Family conference services. 

18 ‘‘(G) Respite services. 

19 ‘‘(H) Onsite caregiver training. 

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

21 under a hospice model of care. 

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

23 ‘family conference services’ means a family conference 

24 held by a hospice program (as so defined) for the indi25 vidual and the family members of the individual, including 

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1 services for the facilitation and provision of adequate fol2 low-up to such family conference, which includes addi3 tional collaboration and coordination with the hospice phy4 sician or other hospice personnel to clarify and put into 

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

6 the family members of the individual. 

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

8 ‘respite services’ means the provision of additional hours 

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

10 activities of daily living. Such services shall be targeted 

11 toward furnishing services to the individual and providing 

12 the caregivers of the individual a needed break outside of 

13 the home of the individual. 

14 ‘‘(B) For purposes of subparagraph (A), the Sec15 retary shall establish, on an annual basis, a minimum and 

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

17 month) for which respite services may be provided to indi18 viduals eligible to receive such services. 

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

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

21 feeding. 

22 ‘‘(4) For purposes of paragraph (1)(H), the term ‘on23 site caregiver training’ means training provided to the 

24 caregivers of an individual, which is focused on training 

25 such caregivers to provide effective personal and technical 

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1 care to individuals, with an emphasis on what the care2 giver can expect with the disease process of the individual 

3 or the needs of the individual at the end of life. Such train4 ing shall be pragmatic and easily understood by non5 health professionals as well as culturally and educationally 

6 appropriate. 

7 ‘‘(5) In the case of a hospice program that is fur8 nishing advanced illness care management services to an 

9 individual who becomes eligible for hospice care under this 

10 title, the hospice program shall notify the individual of 

11 such eligibility.’’. 

12 (3) PAYMENT BASED ON THE PHYSICIAN FEE

13 SCHEDULE.—Section 1814(i)(4) of the Social Secu14 rity Act (42 U.S.C. 1395f(i)(4)) is amended to read 

15 as follows: 

16 ‘‘(4) The amount paid to a hospice program with re17 spect to the advanced illness care management services (as 

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

19 made under this part shall be— 

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

21 respite services, furnished by a hospice physician, an 

22 amount equal to the amount that would be paid for 

23 an equivalent physician consultation under the fee 

24 schedule established under section 1848(b); 

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

2 respite services, furnished by other hospice per3 sonnel, an amount equal to 85 percent of such fee 

4 schedule amount; and 

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

6 shall be at an appropriate rate to be determined by 

7 the Secretary’’. 

8 (4) CONFORMING AMENDMENTS.—Section 

9 1862(a) of the Social Security Act (42 U.S.C. 

10 1395y(a)) is amended— 

11 (A) in paragraph (1)— 

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

13 subparagraph (N); 

14 (ii) by striking the semicolon at the 

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

16 and’’; and 

17 (iii) by adding at the end the fol18 lowing new subparagraph: 

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

20 management services which are respite services 

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

22 performed more frequently than is provided 

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

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

25 and inserting ‘‘(K), or (P)’’. 

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1 (5) EFFECTIVE DATE.—The amendments made 

2 by this subsection shall apply to services furnished 

3 on or after January 1, 2011. 

4 (b) MEDICAID COVERAGE OF ADVANCED ILLNESS

5 CARE MANAGEMENT SERVICES.— 

6 (1) IN GENERAL.—Section 1905(a) of the So7 cial Security Act (42 U.S.C. 1396d(a)) is amend8 ed— 

9 (A) by redesignating paragraph (28) as 

10 paragraph (29); 

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

12 end ‘‘and’’; and 

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

14 following new paragraph: 

15 ‘‘(28) advanced illness care management serv16 ices (as defined in section 1861(hhh)) for individuals 

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

18 (2) CONFORMING AMENDMENT.—Section 

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

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

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

22 (3) EFFECTIVE DATE.— 

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

24 subparagraph (B), the amendments made by 

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

2 1, 2011. 

3 (B) EXTENSION OF EFFECTIVE DATE FOR

4 STATE LAW AMENDMENT.—In the case of a 

5 State plan under title XIX of the Social Secu6 rity Act (42 U.S.C. 1396 et seq.) which the 

7 Secretary determines requires State legislation 

8 in order for the plan to meet the additional re9 quirements imposed by the amendments made 

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

11 regarded as failing to comply with the require12 ments of such title solely on the basis of its fail13 ure to meet these additional requirements be14 fore the first day of the first calendar quarter 

15 beginning after the close of the first regular 

16 session of the State legislature that begins after 

17 the date of enactment of this Act. For purposes 

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

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

20 of the session is considered to be a separate 

21 regular session of the State legislature. 

22 (c) EDUCATION ON ADVANCED ILLNESS CARE MAN23 AGEMENT SERVICES.—The Secretary of Health and 

24 Human Services (in this section referred to as the ‘‘Sec25 retary’’) shall establish a program under which physicians 

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

2 Security Act (42 U.S.C. 1395x)) are educated on the cov3 erage of advanced illness care management services (as de4 fined in subsection (hhh) of such section) under the Medi5 care and Medicaid programs under titles XVIII and XIX, 

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

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

8 intervention in providing such care to individuals. 

9 SEC. 3. INCREASING AWARENESS OF THE IMPORTANCE OF 

10 END-OF-LIFE PLANNING. 

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

12 241 et seq.) is amended by adding at the end the following 

13 new part: 

14 ‘‘PART S—PROGRAMS TO INCREASE AWARENESS 

15 OF ADVANCE CARE PLANNING ISSUES 

16 ‘‘SEC. 399GG. ADVANCE CARE PLANNING EDUCATION CAM17 PAIGNS AND INFORMATION PHONE LINE AND 

18 CLEARINGHOUSE. 

19 ‘‘(a) ADVANCE CARE PLANNING EDUCATION CAM20 PAIGN.—The Secretary shall, directly or through grants 

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

22 education campaign— 

23 ‘‘(1) to raise public awareness of the impor24 tance of planning for care near the end of life; 

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

2 the various situations in which individuals may find 

3 themselves if they become unable to express their 

4 health care wishes; 

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

6 legal documents that express an individual’s wishes 

7 through— 

8 ‘‘(A) advance directives (including living 

9 wills, comfort care orders, and durable powers 

10 of attorney for health care); and 

11 ‘‘(B) other planning tools, such as a physi12 cian’s orders for life-sustaining treatment 

13 (POLST); and 

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

15 of hospice care and palliative care. 

16 ‘‘(b) INFORMATION PHONE LINE AND CLEARING17 HOUSE.—The Secretary, directly or through grants 

18 awarded under subsection (c), shall provide for the estab19 lishment of a national, toll-free, information telephone line 

20 and a clearinghouse that the public and health care profes21 sionals may access to find out about State-specific and 

22 other information regarding advance directive and end-of23 life decisions. 

24 ‘‘(c) GRANTS.— 

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

2 funds appropriated under subsection (d) for the pur3 pose of awarding grants to public or nonprofit pri4 vate entities (including States or political subdivi5 sions of a State), or a consortium of any of such en6 tities, for the purpose of conducting education cam7 paigns under subsection (a). 

8 ‘‘(2) PERIOD.—Any grant awarded under para9 graph (1) shall be for a period of 3 years. 

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

11 are authorized to be appropriated— 

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

13 (b), $5,000,000 for fiscal year 2010 and each subse14 quent year; and 

15 ‘‘(2) for purposes of making grants under sub16 section (c), $10,000,000 for fiscal year 2010, to re17 main available until expended.’’. 

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

19 IN THE MEDICARE & YOU HANDBOOK. 

20 (a) IN GENERAL.—Section 1804(a) of the Social Se21 curity Act (42 U.S.C. 1395b–2(a)) is amended— 

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

23 end; 

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

25 the end and inserting ‘‘; and’’; and 

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1 (3) by inserting after paragraph (3) the fol2 lowing new paragraph: 

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

4 end-of-life planning tools, and the hospice care ben5 efit under this title.’’. 

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

7 this section shall apply to notices distributed on or after 

8 January 1, 2011. 

9 SEC. 5. SENIOR NAVIGATION ADVISORY BOARD. 

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

11 Human Services shall establish the Senior Navigation Ad12 visory Board (in this section referred to as the ‘‘Advisory 

13 Board’’). 

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

15 advocates, researchers, government officials, health care 

16 providers, ethicists, caregivers, and other individuals with 

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

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

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

20 care planning, including how to— 

21 (1) increase patients’ quality of life; 

22 (2) reduce current legal hurdles to the enforce23 ment of advance directives; 

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1 (3) encourage provider participation in edu2 cational and training activities surrounding ad3 vanced illnesses and end-of-life care planning; 

4 (4) develop quality and outcome measures that 

5 hospice programs should report for advanced illness 

6 care management services (as defined in section 

7 1861(hhh) of the Social Security Act, as added by 

8 section 2); 

9 (5) determine what information should be dis10 cussed in discharge planning; and 

11 (6) enhance advance care planning. 

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

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

14 Board. 

15 (e) PAY AND REIMBURSEMENT.— 

16 (1) NO COMPENSATION FOR MEMBERS OF ADVI17 SORY BOARD.—Except as provided in paragraph (2), 

18 a member of the Advisory Board may not receive 

19 pay, allowances, or benefits by reason of their serv20 ice on the Board. 

21 (2) TRAVEL EXPENSES.—Each member shall 

22 receive travel expenses, including per diem in lieu of 

23 subsistence under subchapter I of chapter 57 of title 

24 5, United States Code. 

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1 (f) REPORT.—Not later than 3 years after the estab2 lishment of the Advisory Board, the Advisory Board shall 

3 submit to Congress a final report containing the findings 

4 and conclusions of the Advisory Board, together with rec5 ommendations for such legislation and administrative ac6 tions as the Advisory Board considers appropriate. 

7 (g) TERMINATION.—The Advisory Board shall termi8 nate 30 days after submitting the report under subsection 

9 (f). 

10 (h) AUTHORIZATION OF APPROPRIATIONS.—There 

11 are authorized to be appropriated such sums as may be 

12 necessary to carry out this section. 

13 SEC. 6. REQUIREMENT FOR PHYSICIANS AND NURSE PRAC14 TITIONERS TO PROVIDE CERTAIN MEDICARE 

15 BENEFICIARIES WITH INFORMATION ON AD16 VANCE DIRECTIVES AND OTHER END-OF-LIFE 

17 PLANNING TOOLS. 

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

19 1395m) is amended by adding at the end the following 

20 new subsection: 

21 ‘‘(n) REQUIREMENT FOR PHYSICIANS AND NURSE

22 PRACTITIONERS TO PROVIDE CERTAIN INDIVIDUALS

23 WITH INFORMATION ON ADVANCE DIRECTIVES AND

24 OTHER END-OF-LIFE PLANNING TOOLS.— 

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

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

3 1861(r)) or a nurse practitioner (as defined in sec4 tion 1861(aa)(5)(A)) for items and services fur5 nished on or after January 1, 2014, unless the phy6 sician or nurse practitioner agrees (under a process 

7 established by the Secretary) to provide individuals 

8 described in paragraph (2) with information on ad9 vance directives and other end-of-life planning tools. 

10 Such information shall be provided in a form and 

11 manner, and at a time, determined appropriate by 

12 the Secretary. 

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

14 described in this paragraph is an individual entitled 

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

16 for benefits under this part with— 

17 ‘‘(A) metastatic solid organ cancer; 

18 ‘‘(B) congestive heart failure; 

19 ‘‘(C) end stage renal disease; 

20 ‘‘(D) a progressive neurodegenerative dis21 order; 

22 ‘‘(E) oxygen dependent chronic pulmonary 

23 disease; or 

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

2 level of medical necessity determined appro3 priate by the Secretary.’’. 

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

5 AND PORTABILITY OF ADVANCE DIRECTIVES. 

6 (a) MEDICARE.—Section 1866(f) of the Social Secu7 rity Act (42 U.S.C. 1395cc(f)) is amended— 

8 (1) in paragraph (1)— 

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

10 ‘‘and if presented by the individual (or on be11 half of the individual), to include the content of 

12 such advance directive in a prominent part of 

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

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

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

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

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

18 (D) by inserting after subparagraph (E) 

19 the following new subparagraph: 

20 ‘‘(F) to provide each individual with the oppor21 tunity to discuss issues relating to the information 

22 provided to that individual pursuant to subpara23 graph (A) with an appropriately trained profes24 sional.’’; 

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

2 and inserting ‘‘an’’; and 

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

4 paragraph: 

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

6 (1), a provider of services, Medicare Advantage organiza7 tion, or prepaid or eligible organization (as the case may 

8 be) shall give effect to an advance directive executed out9 side the State in which such directive is presented, even 

10 one that does not appear to meet the formalities of execu11 tion, form, or language required by the State in which it 

12 is presented to the same extent as such provider or organi13 zation would give effect to an advance directive that meets 

14 such requirements, except that a provider or organization 

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

16 organization can reasonably demonstrate that it is not an 

17 authentic expression of the individual’s wishes concerning 

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

19 be construed to authorize the administration of medical 

20 treatment otherwise prohibited by the laws of the State 

21 in which the directive is presented. 

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

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

24 such provisions. The provisions of this paragraph shall not 

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1 ability, more deference to a patient’s wishes, or more lati2 tude in determining a patient’s wishes.’’. 

3 (b) MEDICAID.—Section 1902(w) of the Social Secu4 rity Act (42 U.S.C. 1396a(w)) is amended— 

5 (1) in paragraph (1)— 

6 (A) in subparagraph (B)— 

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

8 medical record’’ and inserting ‘‘in a promi9 nent part of the individual’s current med10 ical record’’; and 

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

12 the individual (or on behalf of the indi13 vidual), to include the content of such ad14 vance directive in a prominent part of such 

15 record’’ before the semicolon at the end; 

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

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

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

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

20 (D) by inserting after subparagraph (E) 

21 the following new subparagraph: 

22 ‘‘(F) to provide each individual with the oppor23 tunity to discuss issues relating to the information 

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1 graph (A) with an appropriately trained profes2 sional.’’; 

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

4 and inserting ‘‘an’’; and 

5 (3) by adding at the end the following para6 graph: 

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

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

9 give effect to an advance directive executed outside the 

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

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

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

13 to the same extent as such provider or organization would 

14 give effect to an advance directive that meets such require15 ments, except that a provider or organization may decline 

16 to honor such a directive if the provider or organization 

17 can reasonably demonstrate that it is not an authentic ex18 pression of the individual’s wishes concerning his or her 

19 health care. Nothing in this paragraph shall be construed 

20 to authorize the administration of medical treatment oth21 erwise prohibited by the laws of the State in which the 

22 directive is presented. 

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

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

25 such provisions. The provisions of this paragraph shall not 

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1 preempt any State law that provides for greater port2 ability, more deference to a patient’s wishes, or more lati3 tude in determining a patient’s wishes.’’. 

4 (c) EFFECTIVE DATES.— 

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

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

7 shall apply to provider agreements and contracts en8 tered into, renewed, or extended under title XVIII of 

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

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

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

12 Secretary of Health and Human Services specifies, 

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

14 after the date of enactment of this Act. 

15 (2) EXTENSION OF EFFECTIVE DATE FOR

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

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

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

19 and Human Services determines requires State legis20 lation in order for the plan to meet the additional 

21 requirements imposed by the amendments made by 

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

23 as failing to comply with the requirements of such 

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

25 additional requirements before the first day of the 

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1 first calendar quarter beginning after the close of 

2 the first regular session of the State legislature that 

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

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

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

6 of the session is considered to be a separate regular 

7 session of the State legislature. 

8 SEC. 8. ADDITIONAL REQUIREMENTS FOR FACILITIES. 

9 (a) REQUIREMENTS.— 

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

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

12 amended— 

13 (A) in subsection (a)(1)— 

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

15 ‘‘and’’ at the end; 

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

17 the period at the end and inserting a 

18 comma; and 

19 (iii) by inserting after subparagraph 

20 (V) the following new subparagraphs: 

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

22 facilities, home health agencies, and hospice pro23 grams, to provide individuals receiving care by or 

24 through the provider (and their caregivers and fami25 lies, with the patient’s consent, or their surrogate 

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1 decisionmakers) with the opportunity to discuss the 

2 general course of treatment expected, the likely im3 pact on length of life and function, and the proce4 dures they should use to secure help if an unex5 pected situation arises, and 

6 ‘‘(X) in the case of hospitals, skilled nursing fa7 cilities, and hospice programs, to— 

8 ‘‘(i) provide for an assessment of each indi9 vidual (at the time of discharge from the pro10 vider) using an assessment instrument that is 

11 at least as informative as the continuity assess12 ment record and evaluation (CARE) instrument 

13 developed by the Centers for Medicare & Med14 icaid Services; and 

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

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

17 (2) EFFECTIVE DATE.—The amendments made 

18 by this subsection shall apply to agreements entered 

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

20 (b) HHS STUDY AND REPORT ON APPROPRIATE AS21 SESSMENTS AT DISCHARGE.— 

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

23 Human Services shall conduct a study on the extent 

24 to which the assessment of individual by hospitals, 

25 skilled nursing facilities, and hospice programs 

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

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

3 the actual diagnosis and care plan of the individual 

4 involved at the time of discharge. 

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

6 the Secretary of Health and Human Services shall 

7 submit to Congress a report on the study conducted 

8 under paragraph (1) together with recommendations 

9 for such legislation and administrative action as the 

10 Secretary determines to be appropriate. 

11 SEC. 9. REQUIREMENT FOR MEDICARE PROVIDERS TO 

12 HONOR WRITTEN ORDERS FOR MEDICAL 

13 CARE. 

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

15 1395m), as amended by section 6, is amended by adding 

16 at the end the following new subsection: 

17 ‘‘(o) REQUIREMENT TO HONOR WRITTEN ORDERS

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

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

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

21 the provider or supplier agrees (under a process estab22 lished by the Secretary) to, in the case of an individual 

23 with a written order for medical care (such as a physi24 cian’s orders for life-sustaining treatment (POLST)), folmstockstill on DSKH9S0YB1PROD with BILLS

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1 low such order when furnishing items and services to the 

2 individual.’’. 

3 SEC. 10. INCENTIVES FOR ACCREDITATION AND CERTIFI4 CATION IN HOSPICE AND PALLIATIVE CARE. 

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

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

7 the following new subsection: 

8 ‘‘(o) INCENTIVES FOR ACCREDITATION IN PALLIA9 TIVE CARE.— 

10 ‘‘(1) INCENTIVE PAYMENT.— 

11 ‘‘(A) IN GENERAL.—Subject to subpara12 graph (3), with respect to inpatient hospital 

13 services and inpatient critical access hospital 

14 services furnished by an eligible hospital during 

15 a payment year, if the eligible hospital has in 

16 place an accredited palliative care program (as 

17 determined by the Secretary) with respect to 

18 such year and meets utilization criteria for such 

19 program (as established by the Secretary) with 

20 respect to such year, in addition to the amount 

21 otherwise paid under this section or section 

22 1814, there shall also be paid to the eligible 

23 hospital, from the Federal Hospital Insurance 

24 Trust Fund established under section 1817, an 

25 amount equal to the applicable percent of the 

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1 amount that would otherwise be paid under this 

2 section or section 1814 for such services for the 

3 hospital for such year. 

4 ‘‘(B) APPLICABLE PERCENT DEFINED.— 

5 The term ‘applicable percent’ means— 

6 ‘‘(i) for fiscal years 2011 through 

7 2016, 2 percent; and 

8 ‘‘(ii) for fiscal years 2017 through 

9 2020, 1 percent. 

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

11 under this paragraph for a payment year may 

12 be in the form of a single consolidated payment 

13 or in the form of such periodic installments as 

14 the Secretary may specify. 

15 ‘‘(2) INCENTIVE PAYMENT ADJUSTMENT.—Sub16 ject to paragraph (3), with respect to inpatient hos17 pital services and inpatient critical access hospital 

18 services furnished by an eligible hospital during a 

19 fiscal year after fiscal year 2020, if the eligible hos20 pital does not have in place an accredited palliative 

21 care program (as determined by the Secretary) with 

22 respect to such fiscal year, the amount otherwise 

23 paid under this section or section 1814 for such 

24 services for the hospital for the year shall be reduced 

25 by 1 percent. 

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

2 hospital with fewer than 50 beds, such hospital shall 

3 be deemed to meet the requirement in paragraphs 

4 (1)(A) and (2) if, in lieu of having in place an ac5 credited palliative care program, the hospital pro6 vides patients and family members with access to a 

7 local or regional accredited palliative care team or 

8 program. 

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

10 ‘‘(A) ELIGIBLE HOSPITAL.—The term ‘eli11 gible hospital’ means— 

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

13 1861(e)); and 

14 ‘‘(ii) a critical access hospital (as de15 fined in section 1861(mm)(1)). 

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

17 year’ means fiscal years 2011 through 2020. 

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

19 no administrative or judicial review under section 

20 1869, section 1878, or otherwise, of— 

21 ‘‘(A) the methodology and standards for 

22 determining payment amounts under paragraph 

23 (1) and payment adjustments under paragraph 

24 (2); 

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1 ‘‘(B) the methodology and standards for 

2 determining whether the eligible hospital has in 

3 place an accredited palliative care program; and 

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

5 paragraph (3).’’. 

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

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

8 by adding at the end the following new subsection: 

9 ‘‘(f) INCENTIVES FOR ACCREDITATION IN PALLIA10 TIVE CARE.— 

11 ‘‘(1) INCENTIVE PAYMENT.— 

12 ‘‘(A) IN GENERAL.—Subject to subpara13 graph (3), with respect to covered skilled nurs14 ing facility services (as defined in subsection 

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

16 during a payment year, if the facility has in 

17 place an accredited palliative care program (as 

18 determined by the Secretary) with respect to 

19 such year and meets utilization criteria for such 

20 program (as established by the Secretary) with 

21 respect to such year, in addition to the amount 

22 otherwise paid under this subsection (e), there 

23 shall also be paid to the facility, from the Fed24 eral Hospital Insurance Trust Fund established 

25 under section 1817, an amount equal to the apmstockstill on DSKH9S0YB1PROD with BILLS

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1 plicable percent of the amount that would oth2 erwise be paid under subsection (e) for such 

3 services for the facility for such year. 

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

5 ‘‘(i) APPLICABLE PERCENT.—The 

6 term ‘applicable percent’ means— 

7 ‘‘(I) for fiscal years 2011 

8 through 2016, 2 percent; and 

9 ‘‘(II) for fiscal years 2017 

10 through 2020, 1 percent. 

11 ‘‘(ii) PAYMENT YEAR.—The term 

12 ‘payment year’ means fiscal years 2011 

13 through 2020. 

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

15 under this paragraph for a payment year may 

16 be in the form of a single consolidated payment 

17 or in the form of such periodic installments as 

18 the Secretary may specify. 

19 ‘‘(2) INCENTIVE PAYMENT ADJUSTMENT.—Sub20 ject to paragraph (3), with respect to covered skilled 

21 nursing facility services (as defined in subsection 

22 (e)(2)(A)) furnished by a skilled nursing facility dur23 ing a fiscal year after fiscal year 2020, if the facility 

24 does not have in place an accredited palliative care 

25 program (as determined by the Secretary) with remstockstill on DSKH9S0YB1PROD with BILLS

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1 spect to such fiscal year, the amount otherwise paid 

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

3 for the year shall be reduced by 1 percent. 

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

5 nursing facility with fewer than 60 beds, such facil6 ity shall be deemed to meet the requirement in para7 graphs (1)(A) and (2) if, in lieu of having in place 

8 an accredited palliative care program, the facility 

9 provides patients and family members with access to 

10 a local or regional accredited palliative care team or 

11 program. 

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

13 no administrative or judicial review under section 

14 1869, section 1878, or otherwise, of— 

15 ‘‘(A) the methodology and standards for 

16 determining payment amounts under paragraph 

17 (1) and payment adjustments under paragraph 

18 (2); 

19 ‘‘(B) the methodology and standards for 

20 determining whether the skilled nursing facility 

21 has in place an accredited palliative care pro22 gram; and 

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

24 paragraph (3).’’. 

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

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

3 end the following new subsection: 

4 ‘‘(p) INCENTIVES FOR CERTIFICATION IN HOSPICE

5 AND PALLIATIVE CARE.— 

6 ‘‘(1) INCENTIVE PAYMENT.— 

7 ‘‘(A) IN GENERAL.—With respect to physi8 cians’ services furnished by a physician during 

9 a payment year, if the physician is certified in 

10 hospice and palliative care (as determined by 

11 the Secretary) with respect to such year, in ad12 dition to the amount otherwise paid under this 

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

14 from the Federal Supplementary Medical Insur15 ance Trust Fund established under section 

16 1841, an amount equal to the applicable per17 cent of the Secretary’s estimate (based on 

18 claims submitted not later than 2 months after 

19 the end of the payment year) of the allowed 

20 charges under this part for all covered profes21 sional services (as defined in subsection (k)(3)) 

22 furnished by the physician during such year. 

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

24 ‘‘(i) APPLICABLE PERCENT.—The 

25 term ‘applicable percent’ means— 

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1 ‘‘(I) for 2011 through 2016, 2 

2 percent; and 

3 ‘‘(II) for 2017 through 2020, 1 

4 percent. 

5 ‘‘(ii) PAYMENT YEAR.—The term 

6 ‘payment year’ means 2011 through 2020. 

7 ‘‘(C) FORM OF PAYMENT.—The payment 

8 under this subsection for a payment year may 

9 be in the form of a single consolidated payment 

10 or in the form of such periodic installments as 

11 the Secretary may specify. 

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

13 no administrative or judicial review under section 

14 1869, section 1878, or otherwise, of— 

15 ‘‘(A) the methodology and standards for 

16 determining payment amounts under paragraph 

17 (1); and 

18 ‘‘(B) the methodology and standards for 

19 determining whether the physician is certified 

20 in hospice and palliative care.’’. 

21 SEC. 11. DISCHARGE CHECKLIST PILOT PROGRAM. 

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

23 the Secretary of Health and Human Services (in this sec24 tion referred to as the ‘‘Secretary’’) shall conduct a pilot 

25 program under title XVIII of the Social Security Act to 

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1 test the use of the Centers for Medicare & Medicaid Serv2 ices’ discharge checklist included in the publication enti3 tled ‘‘Planning for Your Discharge: A checklist for pa4 tients and caregivers preparing to leave a hospital, nursing 

5 home, or other health care setting’’. 

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

7 compliance of such requirements of titles XI and XVIII 

8 of the Social Security Act as the Secretary determines nec9 essary to conduct the pilot program under this section. 

10 (c) REPORT.—Not later than 6 months after the com11 pletion of the pilot program under this section, the Sec12 retary shall submit to Congress a final report on the pilot 

13 program, together with recommendations for such legisla14 tion and administrative action as the Secretary determines 

15 appropriate. 

16 (d) FUNDING.—There are authorized to be appro17 priated such sums as may be necessary for purposes of 

18 conducting the pilot program under this section. 

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

20 (a) ESTABLISHMENT.—The Secretary shall establish 

21 or designate an Office on Medicare/Medicaid Integration 

22 (in this subsection referred to as the ‘‘Office’’) for the pur23 pose of aligning Medicare and Medicaid program policies 

24 and procedures and developing tools to support State inte25 gration efforts in order to— 

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1 (1) simplify dual eligible access to Medicare and 

2 Medicaid program benefits and services; 

3 (2) improve care continuity and ensure safe and 

4 effective care transitions; 

5 (3) eliminate cost shifting between the Medicare 

6 and Medicaid programs and among related care pro7 viders; 

8 (4) eliminate regulatory conflicts between Medi9 care and Medicaid program rules; and 

10 (5) improve total cost and quality performance. 

11 (b) RESPONSIBILITIES.—The responsibilities of the 

12 Office are to develop policies and procedures to— 

13 (1) identify incentives for States to advance the 

14 integration of the Medicare and Medicaid programs 

15 to improve total cost and quality performance, in16 cluding shared cost savings among consumers, plans, 

17 and Federal and State governments with respect to 

18 State initiatives for advancing Medicare and Med19 icaid program integration; 

20 (2) provide support for coordination of Federal 

21 and State contracting and oversight for dual inte22 gration programs supportive of the goals described 

23 in subsection (a); 

24 (3) serve as a liaison between Centers for Medi25 care & Medicaid Services central and regional offices 

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1 to ensure consistent application of Centers for Medi2 care & Medicaid Services rules, policies, and auditing 

3 practices as such rules, policies, and auditing prac4 tices pertain to dual eligibles; 

5 (4) monitor total combined Medicare and Med6 icaid program costs in serving dual eligibles and 

7 make recommendations for optimizing total quality 

8 and cost performance across both programs; and 

9 (5) identify legislative and administrative 

10 changes that are needed to facilitate the integration 

11 of benefits and oversight functions of the Medicare 

12 and Medicaid programs with respect to dual eligi13 bles. 

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

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

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

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

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

19 (2) entitled to medical assistance under a State 

20 plan under title XIX of such Act. 

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

22 Secretary of Health and Human Services, in consultation 

23 with private health information technology stakeholders 

24 and in coordination with other Federal health information 

25 technology efforts, shall conduct a study to determine the 

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1 data that the Office should collect and analyze in order 

2 to improve health care outcomes, create efficiencies in care 

3 delivery, and impact Federal health care spending. 

4 (e) FUNDING.—There are authorized to be appro5 priated such sums as may be necessary to carry out the 

6 provisions of this section. 

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

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

9 Health and Human Services (in this section referred to 

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

11 that provides information, online training, and instruc12 tional materials for entities, including faith-based organi13 zations, on end-of-life issues, which shall include content 

14 addressing— 

15 (1) advance care planning, including common 

16 issues and questions regarding advance directives 

17 and their uses; 

18 (2) hospice benefits under Medicare, Medicaid, 

19 and the State Children’s Health Insurance Program 

20 established under the Social Security Act, including 

21 information on how hospice care is administered and 

22 provided to terminally ill individuals; 

23 (3) palliative care, including information on 

24 services that palliative care units provide for termi25 nally ill patients; and 

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1 (4) any additional information related to end2 of-life care and associated issues, as determined by 

3 the Secretary. 

4 (b) GRANTS.— 

5 (1) HOSPICE CARE GRANT PROGRAM.— 

6 (A) GRANTS AUTHORIZED.—The Secretary 

7 is authorized to award grants to entities, in8 cluding faith-based organizations, to develop 

9 and provide services for terminally ill individ10 uals who are receiving hospice care in their own 

11 homes. 

12 (B) REQUIREMENTS.— 

13 (i) DURATION.—The grant program 

14 shall be conducted for a 5-year period, be15 ginning not later than January 1, 2011. 

16 (ii) AMOUNT OF GRANTS.—An entity 

17 may be awarded a grant under this para18 graph for a fiscal year that is not less than 

19 $5,000 and not more than $250,000. 

20 (iii) NUMBER OF GRANTS.—The Sec21 retary shall award grants under this para22 graph to not more than 100 entities. 

23 (C) ADDITIONAL MEDICAID FUNDS.—A 

24 State may elect to provide additional funds to 

25 recipients of a grant under this section, with 

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1 such funds to be considered as amounts ex2 pended for the proper and efficient administra3 tion of the State plan under title XIX of the 

4 Social Security Act for purposes of the State 

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

6 that Act. 

7 (D) USE OF FUNDS.—Grants awarded 

8 pursuant to this paragraph shall be used by en9 tities to develop and provide end-of-life support 

10 services for terminally ill individuals who are re11 ceiving care in their own homes, including— 

12 (i) support for caregivers; 

13 (ii) if the entity is a hospice program 

14 under the Medicare program, any addi15 tional hospice care determined appropriate 

16 by the Secretary; and 

17 (iii) any additional end-of-life informa18 tion or materials relating to support serv19 ices determined appropriate by the Sec20 retary. 

21 (E) APPLICATION.—Each entity desiring a 

22 grant under this paragraph shall submit an ap23 plication to the Secretary at such time, in such 

24 manner, and accompanied by such information 

25 as the Secretary may reasonably require. 

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1 (F) AUTHORIZATION OF APPROPRIA2 TIONS.—For the purpose of carrying out the 

3 grant program established under this para4 graph, there is authorized to be appropriated 

5 $15,000,000 for the period of fiscal years 2011 

6 through 2015. 

7 (2) END-OF-LIFE EDUCATIONAL GRANT PRO8 GRAM.— 

9 (A) GRANTS AUTHORIZED.—The Secretary 

10 is authorized to award grants to entities, in11 cluding faith-based organizations and religious 

12 educational institutions, to develop and provide 

13 appropriate training and educational programs 

14 addressing end-of-life care issues. 

15 (B) REQUIREMENTS.— 

16 (i) DURATION.—The grant program 

17 shall be conducted for a 5-year period, be18 ginning not later than January 1, 2011. 

19 (ii) AMOUNT OF GRANTS.—An entity 

20 may be awarded a grant under this para21 graph for a fiscal year that is not less than 

22 $5,000, and not more than $50,000. 

23 (iii) NUMBER OF GRANTS.—The Sec24 retary shall award grants under this para25 graph to not more than 100 entities. 

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1 (C) USE OF FUNDS.—Grants awarded pur2 suant to this paragraph shall be used by enti3 ties to develop appropriate training and edu4 cation programs addressing end-of-life care 

5 issues and include such programs as part of 

6 their educational curriculum, continuing edu7 cation programs, or vocational training. 

8 (D) APPLICATION.—Each entity desiring a 

9 grant under this paragraph shall submit an ap10 plication to the Secretary at such time, in such 

11 manner, and accompanied by such information 

12 as the Secretary may reasonably require. 

13 (E) AUTHORIZATION OF APPROPRIA14 TIONS.—For the purpose of carrying out the 

15 grant program established under this para16 graph, there is authorized to be appropriated 

17 $10,000,000 for the period of fiscal years 2011 

18 through 2015. 

19 SEC. 14. HHS STUDY AND REPORT ON THE STORAGE OF AD20 VANCE DIRECTIVES. 

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

22 Services shall conduct a study on the best methods of stor23 ing completed advance directives. Such study shall include 

24 an analysis of the feasibility of establishing a national reg25 istry for completed advance directives, taking into considmstockstill on DSKH9S0YB1PROD with BILLS

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1 eration the constraints created by the privacy provisions 

2 enacted as a result of the Health Insurance Portability 

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

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

5 Secretary of Health and Human Services shall submit to 

6 Congress a report on the study conducted under sub7 section (a) together with recommendations for such legis8 lation and administrative action as the Secretary deter9 mines to be appropriate. 

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

11 AND AMENDMENTS MADE BY, THIS ACT. 

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

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

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

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

16 costs (such as patient and family experience, patient un17 derstanding of treatment choices, and any decrease in 

18 avoidable hospital admissions) associated with such provi19 sions and such amendments. 

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

21 Comptroller General shall submit to Congress a report 

22 containing the results of the study conducted under sub23 section (a), together with recommendations for such legismstockstill on DSKH9S0YB1PROD with BILLS

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1 lation and administrative action as the Comptroller Gen2 eral determines appropriate. 

Æ 

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