I 
114TH CONGRESS 
1ST SESSION H. R. 4059 
To amend title XVIII of the Social Security Act to encourage Medicare 
beneficiaries to voluntarily adopt advance directives guiding the medical 
care they receive. 
IN THE HOUSE OF REPRESENTATIVES 
NOVEMBER 18, 2015 
Mrs. BLACK (for herself, Mr. WELCH, Mr. THOMPSON of California, and Mr. 
COLLINS of New York) introduced the following bill; which was referred 
to the Committee on Energy and Commerce, and in addition to the Com-
mittee 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 encourage 
Medicare beneficiaries to voluntarily adopt advance direc-
tives guiding the medical care they receive. 
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 ‘‘Medicare Choices Em-
powerment and Protection Act’’. 
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SEC. 2. MEDICARE ADVANCE DIRECTIVE CERTIFICATION 
PROGRAM. 
Part B of title XVIII of the Social Security Act (42 
U.S.C. 1395 et seq.) is amended by adding at the end 
the following new section: 
‘‘MEDICARE ADVANCE DIRECTIVE CERTIFICATION 
PROGRAM 
‘‘SEC. 1849. (a) IN GENERAL.— 
‘‘(1) ESTABLISHMENT OF PROGRAM.—The Sec-
retary shall establish and implement an Advance Di-
rective Certification Program (in this section re-
ferred to as the ‘Program’) under which the Sec-
retary shall encourage eligible beneficiaries to adopt 
and maintain certified advance directives to guide 
the delivery of health care to such beneficiaries. The 
Secretary shall implement the Program not later 
than 3 years after the date of enactment of this sec-
tion. 
‘‘(2) DEFINITIONS.—In this section: 
‘‘(A) CERTIFIED
ADVANCE
DIRECTIVE.— 
The term ‘certified advance directive’ means 
any electronically stored statement by an eligi-
ble beneficiary who— 
‘‘(i) provides instructions that outline 
the kind of medical treatments and care 
that such beneficiary would want or not 
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want under particular conditions, and may 
also include the identification of a health 
care proxy or legal representative to make 
medical treatment decisions for the bene-
ficiary if the beneficiary becomes unable to 
make or communicate those decisions; 
‘‘(ii) is executed in accordance with 
the law governing advance directives of the 
State involved; and 
‘‘(iii) is offered by an entity that has 
received accreditation from the Secretary 
under this section. 
‘‘(B) ELIGIBLE BENEFICIARY.—The term 
‘eligible beneficiary’ means an individual en-
rolled under this part. 
‘‘(3) VOLUNTARY.—Participation in the Pro-
gram shall be voluntary with respect to the eligible 
beneficiary and an eligible beneficiary who has reg-
istered a certified advance directive under the Pro-
gram may terminate such directive at any time. 
Nothing in this section shall require an eligible bene-
ficiary to adopt or maintain a certified advance di-
rective. 
‘‘(4) BEST PRACTICES.—In establishing and im-
plementing the Program, the Secretary shall con-
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sider best practices within existing advance directive 
registry technologies, programs, and systems, includ-
ing web-based or cloud-based advance directive tech-
nologies, which may utilize time and date stamps, 
video, or other innovative measures to protect the 
authenticity, improve the quality, and enhance the 
security of such directives. 
‘‘(5) ENROLLMENT
AND
DISENROLLMENT.— 
The Secretary shall establish procedures for eligible 
beneficiaries to enroll and disenroll under the Pro-
gram. Such procedures shall ensure that enrollment 
and disenrollment is available through an online 
process. The Secretary shall also establish proce-
dures to ensure Program participants can update or 
amend an advance directive in a timely and secure 
manner. 
‘‘(6) STATE LAW.—This section shall in no way 
supercede, abrogate, or otherwise interfere with 
State law governing advance directives. Under the 
Program, the Secretary shall establish a process 
under which the Secretary is required to verify that 
digital advance directive vendors or other entities 
providing a digital advance directive participating in 
the program enable those using their services to 
complete advance directives that fully comply with 
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the law governing advance directives of the State in-
volved. 
‘‘(7) DISPLAY
OF
STATUTORY
AND
ALTER-
NATIVE
ADVANCE
DIRECTIVE
FORMS.—Under the 
Program, the Centers for Medicare & Medicaid Serv-
ices shall provide, through a clearinghouse website, 
links to statutory and alternative advance directive 
forms and a State-by-State index to such forms to 
allow a beneficiary to create, adopt, modify, and ter-
minate an advance directive with any content per-
mitted or required, and in any form authorized by 
a State, in accordance with the requirements of sub-
paragraphs (C) through (E) of subsection (e)(1) and 
subsection (e)(2). 
‘‘(8) ACCESS
IN
CASES
OF
DISPUTE
OVER 
TREATMENT.—Under the Program: 
‘‘(A) SPECIAL
ACCESS.—The Secretary 
shall establish a process whereby, with respect 
to a beneficiary with a certified advance direc-
tive, a person described in subparagraph (B) 
may obtain access to the beneficiary’s advance 
directive for the purposes of viewing and shar-
ing such advance directive when— 
‘‘(i) the provisions of the advance di-
rective have come into force under the ap-
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plicable State’s law because the beneficiary 
has become incapable of making health 
care 
decisions 
or 
under 
other 
cir-
cumstances provided under State law; and 
‘‘(ii) at least one person described in 
subparagraph (B) is questioning or dis-
puting the provision, withholding, or with-
drawal of medical treatment, food, or 
fluids with respect to the beneficiary. 
‘‘(B) INTERESTED INDIVIDUALS.—A per-
son described in this subparagraph, with re-
spect to a beneficiary, is— 
‘‘(i) any individual who is a member 
of any class of persons who, under the ap-
plicable State’s law, would potentially be 
eligible to serve as a health care decision 
maker for the beneficiary if an advance di-
rective had not been executed regardless of 
whether higher priority for such eligibility 
would be accorded to another individual or 
individuals; and 
‘‘(ii) if the applicable State’s law does 
not designate persons or classes of persons 
described in clause (i), any person related 
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within the third degree of consanguinity or 
affinity to the beneficiary. 
‘‘(b) REGISTRATION.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish procedures for an eligible beneficiary to register 
such beneficiary’s adoption of a certified advance di-
rective under the Program. Such procedures shall 
ensure that registration is available through an on-
line process. The Secretary shall also establish pro-
cedures to ensure Program participants can update 
previously registered information that is no longer 
accurate and indicate that an advance directive has 
been terminated. 
‘‘(2) REQUIRED INFORMATION.—In addition to 
such other information as the Secretary may deem 
appropriate, an eligible beneficiary seeking to reg-
ister a certified advance directive under the Program 
shall indicate where the advance directive is main-
tained. 
‘‘(3) REGISTRATION PERIODS.—The procedures 
established under paragraph (1) shall provide that 
registration under the Program shall occur during— 
‘‘(A) an eligible beneficiary’s initial enroll-
ment under an MA plan under part C as de-
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scribed in paragraph (1) of section 1851(e); 
and 
‘‘(B) the annual, coordinated election pe-
riod under paragraph (3) of such section. 
‘‘(4) PRIVACY AND SECURITY.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
ensure that all aspects of the registration sys-
tem comply with the Federal regulations (con-
cerning the privacy of individually identifiable 
health information) promulgated under section 
264(c) of the Health Insurance Portability and 
Accountability Act of 1996 subject to the access 
authorized under subsection (a)(8) and sub-
section (c)(2)(D). 
‘‘(B) ACCESS.—The Secretary shall utilize 
standardized data protections and privacy 
standards, including the Federal regulations de-
scribed in paragraph (1), to ensure that the 
registration record of an eligible beneficiary can 
only be accessed by— 
‘‘(i) the beneficiary, through the proc-
ess established under paragraph (1); 
‘‘(ii) those authorized to access the 
advance directive under subsection (a)(8) 
and subsection (c)(2)(D); and 
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‘‘(iii) providers of services and sup-
pliers 
participating 
under 
this 
title, 
through a process established by the Sec-
retary. 
‘‘(c) ACCREDITATION.— 
‘‘(1) IN GENERAL.—Under the Program, the 
Secretary shall— 
‘‘(A) grant accreditation to advance direc-
tive vendors and other entities providing ad-
vance directives that meet the accreditation cri-
teria established under paragraph (2); and 
‘‘(B) establish a process whereby advance 
directive vendors and other entities providing 
advance directives may obtain accreditation 
under this subsection. 
‘‘(2) ACCREDITATION
CRITERIA.—The Sec-
retary, in consultation with the General Accounting 
Office, shall establish accreditation criteria for ad-
vance directive vendors and other entities providing 
advance directives that seek to offer advance direc-
tives to be certified under the Program. Such cri-
teria shall consist of the following: 
‘‘(A) PROCESS
FOR
ADOPTING
ADVANCE 
DIRECTIVE.—The advance directive vendor or 
other entity providing an advance directive shall 
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allow a beneficiary to create, adopt, modify, and 
terminate an advance directive through an on-
line process. 
‘‘(B) VENDORS.—The advance directive 
vendor or other entity providing an advance di-
rective shall comply with an annual quality re-
view to be conducted by the Secretary. 
‘‘(C) USE
OF
STATUTORY
AND
ALTER-
NATIVE ADVANCE DIRECTIVE FORMS.—The ad-
vance directive vendor or other entity providing 
an advance directive shall enable a beneficiary 
to access, complete, modify, and adopt any ad-
vance directive applicable to the State indicated 
by the beneficiary who is posted as provided 
under subparagraphs (C) through (E) of sub-
section (e)(1) and of subsection (e)(2). 
‘‘(D) ACCESS.—The advance directive ven-
dor or other entity providing an advance direc-
tive shall maintain advance directives in such a 
way that— 
‘‘(i) an eligible beneficiary who has 
adopted an advance directive with such 
vendor or entity and any family member, 
legal representative, or health care proxy 
legally designated by such beneficiary has 
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