‘‘(1) IN GENERAL.—No payment may be made 
under this title to a physician (as defined in section 
1861(r)) or a nurse practitioner (as defined in sec-
tion 1861(aa)(5)(A)) for items and services fur-
nished on or after January 1, 2014, unless the phy-
sician or nurse practitioner agrees (under a process 
established by the Secretary) to provide individuals 
described in paragraph (2) with information on ad-
vance directives and other end-of-life planning tools. 
Such information shall be provided in a form and 
manner, and at a time, determined appropriate by 
the Secretary. 
‘‘(2) INDIVIDUAL
DESCRIBED.—An individual 
described in this paragraph is an individual entitled 
to, or enrolled for, benefits under part A or enrolled 
for benefits under this part with— 
‘‘(A) metastatic solid organ cancer; 
‘‘(B) congestive heart failure; 
‘‘(C) end stage renal disease; 
‘‘(D) a progressive neurodegenerative dis-
order; 
‘‘(E) oxygen dependent chronic pulmonary 
disease; or 
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‘‘(F) any other condition with a similar 
level of medical necessity determined appro-
priate by the Secretary.’’. 
SEC. 7. IMPROVEMENT OF POLICIES RELATED TO THE USE 
AND PORTABILITY OF ADVANCE DIRECTIVES. 
(a) MEDICARE.—Section 1866(f) of the Social Secu-
rity Act (42 U.S.C. 1395cc(f)) is amended— 
(1) in paragraph (1)— 
(A) in subparagraph (B), by inserting 
‘‘and if presented by the individual (or on be-
half of the individual), to include the content of 
such advance directive in a prominent part of 
such record’’ before the semicolon at the end; 
(B) in subparagraph (D), by striking 
‘‘and’’ after the semicolon at the end; 
(C) in subparagraph (E), by striking the 
period at the end and inserting ‘‘; and’’; and 
(D) by inserting after subparagraph (E) 
the following new subparagraph: 
‘‘(F) to provide each individual with the oppor-
tunity to discuss issues relating to the information 
provided to that individual pursuant to subpara-
graph (A) with an appropriately trained profes-
sional.’’; 
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(2) in paragraph (3), by striking ‘‘a written’’ 
and inserting ‘‘an’’; and 
(3) by adding at the end the following new 
paragraph: 
‘‘(5)(A) In addition to the requirements of paragraph 
(1), a provider of services, Medicare Advantage organiza-
tion, or prepaid or eligible organization (as the case may 
be) shall give effect to an advance directive executed out-
side the State in which such directive is presented, even 
one that does not appear to meet the formalities of execu-
tion, form, or language required by the State in which it 
is presented to the same extent as such provider or organi-
zation would give effect to an advance directive that meets 
such requirements, except that a provider or organization 
may decline to honor such a directive if the provider or 
organization can reasonably demonstrate that it is not an 
authentic expression of the individual’s wishes concerning 
his or her health care. Nothing in this paragraph shall 
be construed to authorize the administration of medical 
treatment otherwise prohibited by the laws of the State 
in which the directive is presented. 
‘‘(B) The provisions of this paragraph shall preempt 
any State law to the extent such law is inconsistent with 
such provisions. The provisions of this paragraph shall not 
preempt any State law that provides for greater port-
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ability, more deference to a patient’s wishes, or more lati-
tude in determining a patient’s wishes.’’. 
(b) MEDICAID.—Section 1902(w) of the Social Secu-
rity Act (42 U.S.C. 1396a(w)) is amended— 
(1) in paragraph (1)— 
(A) in subparagraph (B)— 
(i) by striking ‘‘in the individual’s 
medical record’’ and inserting ‘‘in a promi-
nent part of the individual’s current med-
ical record’’; and 
(ii) by inserting ‘‘and if presented by 
the individual (or on behalf of the indi-
vidual), to include the content of such ad-
vance directive in a prominent part of such 
record’’ before the semicolon at the end; 
(B) in subparagraph (D), by striking 
‘‘and’’ after the semicolon at the end; 
(C) in subparagraph (E), by striking the 
period at the end and inserting ‘‘; and’’; and 
(D) by inserting after subparagraph (E) 
the following new subparagraph: 
‘‘(F) to provide each individual with the oppor-
tunity to discuss issues relating to the information 
provided to that individual pursuant to subpara-
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graph (A) with an appropriately trained profes-
sional.’’; 
(2) in paragraph (4), by striking ‘‘a written’’ 
and inserting ‘‘an’’; and 
(3) by adding at the end the following para-
graph: 
‘‘(6)(A) In addition to the requirements of paragraph 
(1), a provider or organization (as the case may be) shall 
give effect to an advance directive executed outside the 
State in which such directive is presented, even one that 
does not appear to meet the formalities of execution, form, 
or language required by the State in which it is presented 
to the same extent as such provider or organization would 
give effect to an advance directive that meets such require-
ments, except that a provider or organization may decline 
to honor such a directive if the provider or organization 
can reasonably demonstrate that it is not an authentic ex-
pression of the individual’s wishes concerning his or her 
health care. Nothing in this paragraph shall be construed 
to authorize the administration of medical treatment oth-
erwise prohibited by the laws of the State in which the 
directive is presented. 
‘‘(B) The provisions of this paragraph shall preempt 
any State law to the extent such law is inconsistent with 
such provisions. The provisions of this paragraph shall not 
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preempt any State law that provides for greater port-
ability, more deference to a patient’s wishes, or more lati-
tude in determining a patient’s wishes.’’. 
(c) EFFECTIVE DATES.— 
(1) IN GENERAL.—Subject to paragraph (2), 
the amendments made by subsections (a) and (b) 
shall apply to provider agreements and contracts en-
tered into, renewed, or extended under title XVIII of 
the Social Security Act (42 U.S.C. 1395 et seq.), 
and to State plans under title XIX of such Act (42 
U.S.C. 1396 et seq.), on or after such date as the 
Secretary of Health and Human Services specifies, 
but in no case may such date be later than 1 year 
after the date of enactment of this Act. 
(2) EXTENSION
OF
EFFECTIVE
DATE
FOR 
STATE LAW AMENDMENT.—In the case of a State 
plan under title XIX of the Social Security Act (42 
U.S.C. 1396 et seq.) which the Secretary of Health 
and Human Services determines requires State legis-
lation in order for the plan to meet the additional 
requirements imposed by the amendments made by 
subsection (b), the State plan shall not be regarded 
as failing to comply with the requirements of such 
title solely on the basis of its failure to meet these 
additional requirements before the first day of the 
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first calendar quarter beginning after the close of 
the first regular session of the State legislature that 
begins after the date of enactment of this Act. For 
purposes of the previous sentence, in the case of a 
State that has a 2-year legislative session, each year 
of the session is considered to be a separate regular 
session of the State legislature. 
SEC. 8. ADDITIONAL REQUIREMENTS FOR FACILITIES. 
(a) REQUIREMENTS.— 
(1) IN GENERAL.—Section 1866(a)(1) of the 
Social Security Act (42 U.S.C. 1395cc(a)(1)) is 
amended— 
(A) in subsection (a)(1)— 
(i) in subparagraph (U), by striking 
‘‘and’’ at the end; 
(ii) in subparagraph (V), by striking 
the period at the end and inserting a 
comma; and 
(iii) by inserting after subparagraph 
(V) the following new subparagraphs: 
‘‘(W) in the case of hospitals, skilled nursing 
facilities, home health agencies, and hospice pro-
grams, to provide individuals receiving care by or 
through the provider (and their caregivers and fami-
lies, with the patient’s consent, or their surrogate 
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decisionmakers) with the opportunity to discuss the 
general course of treatment expected, the likely im-
pact on length of life and function, and the proce-
dures they should use to secure help if an unex-
pected situation arises, and 
‘‘(X) in the case of hospitals, skilled nursing fa-
cilities, and hospice programs, to— 
‘‘(i) provide for an assessment of each indi-
vidual (at the time of discharge from the pro-
vider) using an assessment instrument that is 
at least as informative as the continuity assess-
ment record and evaluation (CARE) instrument 
developed by the Centers for Medicare & Med-
icaid Services; and 
‘‘(ii) include the results of such assessment 
in the individual’s medical record.’’. 
(2) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply to agreements entered 
into or renewed on or after January 1, 2012. 
(b) HHS STUDY AND REPORT ON APPROPRIATE AS-
SESSMENTS AT DISCHARGE.— 
(1) STUDY.—The Secretary of Health and 
Human Services shall conduct a study on the extent 
to which the assessment of individual by hospitals, 
skilled nursing facilities, and hospice programs 
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under section 1886(a)(1)(X) of the Social Security 
Act, as added by subsection (a), accurately reflects 
the actual diagnosis and care plan of the individual 
involved at the time of discharge. 
(2) REPORT.—Not later than January 1, 2014, 
the Secretary of Health and Human Services shall 
submit to Congress a report on the study conducted 
under paragraph (1) together with recommendations 
for such legislation and administrative action as the 
Secretary determines to be appropriate. 
SEC. 9. REQUIREMENT FOR MEDICARE PROVIDERS TO 
HONOR WRITTEN ORDERS FOR MEDICAL 
CARE. 
Section 1834 of the Social Security Act (42 U.S.C. 
1395m), as amended by section 6, is amended by adding 
at the end the following new subsection: 
‘‘(o) REQUIREMENT TO HONOR WRITTEN ORDERS 
FOR MEDICAL CARE.—No payment may be made under 
this title to a provider of services or a supplier for items 
and services furnished on or after January 1, 2013, unless 
the provider or supplier agrees (under a process estab-
lished by the Secretary) to, in the case of an individual 
with a written order for medical care (such as a physi-
cian’s orders for life-sustaining treatment (POLST)), fol-
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low such order when furnishing items and services to the 
individual.’’. 
SEC. 10. INCENTIVES FOR ACCREDITATION AND CERTIFI-
CATION IN HOSPICE AND PALLIATIVE CARE. 
(a) HOSPITALS.—Section 1886 of the Social Security 
Act (42 U.S.C. 1395ww) is amended by adding at the end 
the following new subsection: 
‘‘(o) INCENTIVES FOR ACCREDITATION IN PALLIA-
TIVE CARE.— 
‘‘(1) INCENTIVE PAYMENT.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (3), with respect to inpatient hospital 
services and inpatient critical access hospital 
services furnished by an eligible hospital during 
a payment year, if the eligible hospital has in 
place an accredited palliative care program (as 
determined by the Secretary) with respect to 
such year and meets utilization criteria for such 
program (as established by the Secretary) with 
respect to such year, in addition to the amount 
otherwise paid under this section or section 
1814, there shall also be paid to the eligible 
hospital, from the Federal Hospital Insurance 
Trust Fund established under section 1817, an 
amount equal to the applicable percent of the 
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amount that would otherwise be paid under this 
section or section 1814 for such services for the 
hospital for such year. 
‘‘(B) APPLICABLE
PERCENT
DEFINED.— 
The term ‘applicable percent’ means— 
‘‘(i) for fiscal years 2011 through 
2016, 2 percent; and 
‘‘(ii) for fiscal years 2017 through 
2020, 1 percent. 
‘‘(C) FORM OF PAYMENT.—The payment 
under this paragraph for a payment year may 
be in the form of a single consolidated payment 
or in the form of such periodic installments as 
the Secretary may specify. 
‘‘(2) INCENTIVE PAYMENT ADJUSTMENT.—Sub-
ject to paragraph (3), with respect to inpatient hos-
pital services and inpatient critical access hospital 
services furnished by an eligible hospital during a 
fiscal year after fiscal year 2020, if the eligible hos-
pital does not have in place an accredited palliative 
care program (as determined by the Secretary) with 
respect to such fiscal year, the amount otherwise 
paid under this section or section 1814 for such 
services for the hospital for the year shall be reduced 
by 1 percent. 
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