I
107TH CONGRESS
1ST SESSION
H. R. 3492
To establish hospice demonstration projects and a hospice grant program
for beneficiaries under the Medicare Program under title XVIII of the
Social Security Act, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
DECEMBER 13, 2001
Ms. HOOLEY of Oregon introduced the following bill; which was referred to
the Committee on Ways and Means, and in addition to the Committee
on Energy and Commerce, for a period to be subsequently determined by
the Speaker, in each case for consideration of such provisions as fall with-
in the jurisdiction of the committee concerned
A BILL
To establish hospice demonstration projects and a hospice
grant program for beneficiaries under the Medicare Pro-
gram under title XVIII of the Social Security Act, and
for other purposes.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘Hospice Improvement
Program Act of 2001’’.
SEC. 2. FINDINGS.
Congress makes the following findings:
(1) Each year more than 1⁄3 of the people who
die suffer from a chronic illness.
(2) Approximately 1⁄3 of Americans are unsure
about whom to contact to get the best care during
life’s last stages.
(3) Americans want a team of professionals to
care for the patient at the end of life.
(4) Americans want emotional and spiritual
support for the patient and family.
(5) Ninety percent of Americans do not realize
that hospice care is a benefit provided under the
Medicare Program under title XVIII of the Social
Security Act.
(6) Data of the Centers for Medicare & Med-
icaid Services show that beneficiaries were enrolled
in hospice for an average of less than 7 weeks in
1998, far less than the full 6-month benefit under
the Medicare Program.
(7) According to the most recent data available,
although more medicare beneficiaries are enrolled in
hospice, the medicare length of stay has declined.
(8) Use of hospice among medicare beneficiaries
has been decreasing, from a high of 59 days in 1995
to less than 48 days in 1998.
SEC. 3. HOSPICE DEMONSTRATION PROJECTS AND HOS-
PICE EDUCATION GRANTS.
(a) DEFINITIONS.—In this section:
(1) DEMONSTRATION
PROJECT.—The term
‘‘demonstration project’’ means a demonstration
project established by the Secretary under sub-
section (b)(1).
(2) HOSPICE CARE.—The term ‘‘hospice care’’
means the items and services described in subpara-
graphs (A) through (I) of section 1861(dd)(1) of the
Social Security Act (42 U.S.C. 1395x(dd)(1)) that
are provided to a seriously ill medicare beneficiary
under a demonstration project by a hospice program
(or by others under an arrangement with such a
program) under a written plan for providing such
care to such beneficiary established and periodically
reviewed by the beneficiary’s attending physician, by
the medical director of the program, and by the
interdisciplinary 
group 
described 
in 
section
1861(dd)(2)(B) 
of 
such 
Act 
(42 
U.S.C.
1395x(dd)(2)(B)).
(3) HOSPICE
PROGRAM.—The term ‘‘hospice
program’’ has the meaning given that term in sec-
tion 1861(dd)(2) of the Social Security Act (42
U.S.C. 1395x(dd)(2)).
(4) 
MEDICARE
BENEFICIARY.—The 
term
‘‘medicare beneficiary’’ means any individual who is
entitled to benefits under part A or enrolled under
part B of the Medicare Program.
(5) MEDICARE PROGRAM.—The term ‘‘Medicare
Program’’ means the health benefits program under
title XVIII of the Social Security Act (42 U.S.C.
1395 et seq.).
(6) SECRETARY.—The term ‘‘Secretary’’ means
the Secretary of Health and Human Services.
(7) SERIOUSLY ILL.—The term ‘‘seriously ill’’
has the meaning given such term by the Secretary
(in consultation with hospice programs and academic
experts in end-of-life care), except that the Secretary
may not limit such term to individuals who are ter-
minally ill (as defined in section 1861(dd)(3) of the
Social Security Act (42 U.S.C. 1395x(dd)(3))).
(b) HOSPICE DEMONSTRATION PROJECTS.—
(1) ESTABLISHMENT.—The Secretary shall es-
tablish demonstration projects in accordance with
the provisions of this subsection to increase the util-
ity of the hospice care for seriously ill medicare
beneficiaries.
(2) PARTICIPATION.—
(A) HOSPICE PROGRAMS.—Except as pro-
vided in paragraph (4)(A), only a hospice pro-
gram with an agreement under section 1866 of
the Social Security Act (42 U.S.C. 1395cc), a
consortium of such hospice programs, or a
State hospice association may participate in the
demonstration program.
(B) SERIOUSLY
ILL
MEDICARE
BENE-
FICIARIES.—The Secretary shall permit any se-
riously ill medicare beneficiary residing in the
service area of a hospice program participating
in a demonstration project to participate in
such project on a voluntary basis.
(3) 
SERVICES
UNDER
DEMONSTRATION
PROJECTS.—The provisions of section 1814(i) of the
Social Security Act (42 U.S.C. 1395f(i)) shall apply
to the payment for hospice care provided under the
demonstration projects, except that—
(A) notwithstanding section 1862(a)(1)(C)
of such Act (42 U.S.C. 1395y(a)(1)(C)), the
Secretary shall provide for reimbursement for
items and services provided under the sup-
portive and comfort care benefit established
under paragraph (3);
(B) any licensed nurse practitioner or phy-
sician assistant may admit a seriously ill medi-
care beneficiary as the primary care provider
when necessary and within the scope of practice
of such practitioner or assistant under State
law;
(C) if a community does not have a quali-
fied social worker, any professional (other than
a social worker) who has the necessary knowl-
edge, skills, and ability to provide medical social
services may provide such services;
(D) the Secretary shall waive any require-
ment that nursing facilities used for respite
care have skilled nurses on the premises 24
hours per day;
(E) the Secretary shall permit respite care
to be provided to the seriously ill medicare ben-
eficiary at home; and
(F) the Secretary shall waive reimburse-
ment regulations to provide—
(i) reimbursement for consultations
and preadmission informational visits, even
if the seriously ill medicare beneficiary
does not elect hospice care at that time;
(ii) except with respect to the sup-
portive and comfort care benefit under
paragraph (3), a minimum payment for
hospice care provided under the dem-
onstration projects based on the provision
of hospice care to a seriously ill medicare
beneficiary for a period of 14 days, that—
(I) the Secretary shall pay to any
hospice program participating in a
demonstration project and providing
such care (regardless of the length of
stay of the seriously ill medicare bene-
ficiary); and
(II) may not be less than the
amount of payment that would have
been made for hospice care if payment
had been made at the daily rate of
payment for such care under section
1814(i) of the Social Security Act (42
U.S.C. 1395f(i));
(iii) an increase in the reimbursement
rates for hospice care to offset—
(I) changes in hospice care and
oversight under the demonstration
projects;
(II) the higher costs of providing
hospice care in rural areas due to lack
of economies of scale or large geo-
graphic areas; and
(III) the higher costs of pro-
viding hospice care in urban under-
served areas due to unique costs spe-
cifically associated with people living
in those areas, including providing se-
curity;
(iv) direct payment of any nurse prac-
titioner or physician assistant practicing
within the scope of State law in relation to
hospice care provided by such practitioner
or assistant; and
(v) a per diem rate of payment for in-
home care under subparagraph (E) that
reflects the range of care needs of the seri-
ously ill medicare beneficiary and that—
(I) in the case of a seriously ill
medicare beneficiary that needs rou-
tine care, is not less than 150 percent,
and not more than 200 percent, of the
routine home care rate for hospice
care; and
(II) in the case of a seriously ill
medicare beneficiary that needs acute
care, is equal to the continuous home
care day rate for hospice care.
(4) SUPPORTIVE
AND
COMFORT
CARE
BEN-
EFIT.—
(A) IN
GENERAL.—For purposes of the
demonstration projects, the Secretary shall es-
tablish a supportive and comfort care benefit
for any eligible seriously ill medicare beneficiary
(as defined in subparagraph (C)).
(B) PARTICIPATION.—Any individual or
entity with an agreement under section 1866 of
the Social Security Act (42 U.S.C. 1395cc) may
furnish items or services covered under the sup-
portive and comfort care benefit.
(C) BENEFIT.—Under the supportive and
comfort care benefit, any eligible seriously ill
medicare beneficiary may—
(i) continue to receive benefits for dis-
ease and symptom modifying treatment
under the medicare program (and the Sec-
retary may not require or prohibit any spe-
cific treatment or decision);
(ii) receive case management and hos-
pice care through a hospice program par-
ticipating in a demonstration project (for
which payment shall be made under para-
graph (2)(F)(ii)); and
(iii) receive information and education
in order to better understand the utility of
hospice care.
(D) PAYMENT.—The Secretary shall estab-
lish procedures under which the Secretary pays
for items and services furnished to seriously ill
medicare beneficiaries under the supportive and
comfort care benefit on a fee-for-service basis.
(E) ELIGIBLE SERIOUSLY ILL MEDICARE
BENEFICIARY DEFINED.—
(i) IN GENERAL.—In this paragraph,
the term ‘‘eligible seriously ill medicare
beneficiary’’ means any seriously ill medi-
care beneficiary that meets the criteria ap-
proved by the Secretary under clause (ii).
(ii) APPROVAL OF CRITERIA.—
(I) IN
GENERAL.—With respect
to each demonstration project, the
Secretary shall approve criteria for
determining whether a seriously ill
medicare beneficiary is eligible for
hospice care under a demonstration
project that has been developed by
hospice programs in consultation with
researchers in end-of-life care and the
broader medical community.
(II) DATA COMPARABILITY.—The
Secretary may only approve criteria
that ensures that each demonstration
project yields comparable data with
respect to eligible seriously ill medi-
care beneficiaries on—
(aa) the utilization of serv-
ices by such beneficiaries;
(bb) the cost of providing
services to such beneficiaries, in-
cluding any costs associated with
providing services before an indi-
vidual is terminally ill (as defined
in section 1861(dd)(3)(A) of the
Social Security Act (42 U.S.C.
1395x(dd)(3)(A))); and
(cc) the effect of the dem-
onstration project on the quality
of care of such beneficiaries.
(III) 
LIMITATION.—The 
Sec-
retary may not approve criteria if the
purpose of such criteria is to segment
services or to provide a benefit for the
chronically ill.
(5) 
CONDUCT
OF
DEMONSTRATION
PROJECTS.—
(A) SITES.—The Secretary shall conduct
demonstration projects in at least 3, but not
more than 6, sites (which may be statewide).
(B) SELECTION OF SITES.—
(i) IN GENERAL.—Except as provided
in clause (ii), the Secretary shall select
demonstration sites on the basis of pro-
posals submitted under subparagraph (C)
that are located in geographic areas that—
(I) include both urban and rural
hospice programs; and
(II) are geographically diverse
and readily accessible to a significant
number of seriously ill medicare bene-
ficiaries.
(ii) EXCEPTIONS.—
(I) 
UNDERSERVED
URBAN
AREAS.—If a geographic area does
not have any rural hospice program
available to participate in a dem-
onstration project, such area may sub-
stitute an underserved urban area,
but the Secretary shall give priority to
those proposals that include a rural
hospice program.
(II) SPECIFIC
SITE.—The Sec-
retary shall select as a demonstration
site the State in which (according to
the Hospital Referral Region of Resi-
dence, 1994–1995, as listed in the
Dartmouth Atlas of Health Care
1998) the largest metropolitan area of
the State had the lowest percentage of
medicare beneficiary deaths in a hos-
pital when compared to the largest
metropolitan area of each other State,
and the percentage of enrollees who
experienced intensive care during the
last 6 months of life was 21.5 percent.
(C) PROPOSALS.—
(i) IN GENERAL.—The Secretary shall
accept proposals by any State hospice asso-
ciation, hospice program, or consortium of
hospice programs at such time, in such
manner, and in such form as the Secretary
may reasonably require.
(ii) RESEARCH
DESIGNS.—The Sec-
retary shall permit research designs that
use time series, sequential implementation
of the intervention, randomization by wait
list, and other designs that allow the
strongest possible implementation of the
demonstration projects, while still allowing
strong evaluation about the merits of the
demonstration projects.
(D) FACILITATION OF EVALUATION.—The
Secretary shall design the program to facilitate
the evaluation conducted under paragraph (7).
(6) DURATION.—The Secretary shall complete
the demonstration projects within a period of 61⁄2
years that includes a period of 18 months during
which the Secretary shall complete the evaluation
under paragraph (7).
(7) EVALUATION.—During the 18-month period
following the first 5 years of the demonstration
projects, the Secretary shall complete an evaluation
of 
the 
demonstration 
projects 
in 
order 
to
determine—
(A) the short-term and long-term costs and
benefits of changing hospice care provided
under the Medicare Program to include the
items, services, and reimbursement options pro-
vided under the demonstration projects;
(B) whether any increase in payments for
the hospice care provided under the Medicare
Program are offset by savings in other parts of
the medicare program;
(C) the projected cost of implementing the
demonstration projects on a national basis; and
(D) in consultation with hospice organiza-
tions and hospice programs (including organiza-
tions and providers that represent rural areas),
whether a payment system based on diagnosis-
related groups is useful for administering the
hospice care provided under the Medicare Pro-
gram.
(8) REPORTS TO CONGRESS.—
(A) PRELIMINARY
REPORT.—Not later
than 3 years after the date of enactment of this
Act, the Secretary shall submit to the Com-
mittee on Ways and Means of the House of
Representatives and to the Committee on Fi-
nance of the Senate a preliminary report on the
progress made in the demonstration projects.
(B) INTERIM REPORT.—Not later than 30
months after the implementation of the dem-
onstration projects, the Secretary, in consulta-
tion with participants in the projects, shall sub-
mit to the committees described in subpara-
graph (A) an interim report on the demonstra-
tion projects.
(C) FINAL REPORT.—Not later than the
date on which the demonstration projects end,
the Secretary shall submit a final report to the
committees described in subparagraph (A) on
the demonstration projects that includes the re-
sults of the evaluation conducted under para-
graph (7) and recommendations for appropriate
legislative changes.
(9) WAIVER OF MEDICARE REQUIREMENTS.—
The Secretary shall waive compliance with such re-
quirements of the medicare program to the extent
and for the period the Secretary finds necessary to
conduct the demonstration projects.
(10) 
SPECIAL
RULES
FOR
PAYMENT
OF
MEDICARE+CHOICE
ORGANIZATIONS.—The 
Sec-
retary shall establish procedures under which the
Secretary provides for an appropriate adjustment in
the monthly payments made under section 1853 of
the Social Security Act (42 U.S.C. 1395w–23) to
any 
Medicare+Choice 
organization 
offering 
a
Medicare+Choice plan to reflect the participation of
each seriously ill medicare beneficiary enrolled in
such plan in a demonstration project.
(c) HOSPICE EDUCATION GRANT PROGRAM.—
(1) IN GENERAL.—The Secretary shall establish
a Hospice Education Grant program under which
the Secretary awards education grants to entities
participating in the demonstration projects for the
purpose of providing information about—
(A) the hospice care under the medicare
program; and
(B) the benefits available to medicare
beneficiaries under the demonstration projects.
(2) USE
OF
FUNDS.—Grants awarded under
paragraph (1) shall be used—
(A) to provide—
(i) individual or group education to
medicare beneficiaries and the families of
such beneficiaries; and
(ii) individual or group education of
the medical and mental health community
caring for medicare beneficiaries; and
(B) to test strategies to improve the gen-
eral public knowledge about hospice care under
the medicare program and the benefits available
to medicare beneficiaries under the demonstra-
tion projects.
(d) FUNDING.—
(1) HOSPICE DEMONSTRATION PROJECTS.—
(A) IN GENERAL.—Except as provided in
subparagraph (B), the Secretary shall provide
for the transfer from the Federal Hospital In-
surance Trust Fund under section 1817 of the
Social Security Act (42 U.S.C. 1395i) such
sums as may be necessary to carry out this sec-
tion.
(B) SUPPORTIVE
AND
COMFORT
CARE
BENEFIT.—The Secretary shall provide for the
transfer from the Federal Hospital Insurance
Trust Fund under section 1817 of the Social
Security Act (42 U.S.C. 1395i) and the Federal
Supplementary Medical Insurance Trust Fund
established under section 1841 of such Act (42
U.S.C. 1395t), in such proportion as the Sec-
retary determines is appropriate, such sums as
may be necessary to provide for payment of the
costs attributable to the supportive and comfort
care benefit.
(2) HOSPICE EDUCATION GRANTS.—The Sec-
retary shall expend such sums as may be necessary
for the purposes of carrying out the Hospice Edu-
cation Grant program established under subsection
(c)(1) from the Research and Demonstration Budget
of the Centers for Medicare & Medicaid Services.
Æ