		I
		111th CONGRESS
		1st Session
		H. R. 2911
		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.Short title; table of
			 contents
			(a)Short
			 titleThis Act may be cited
			 as the Advance Planning and
			 Compassionate Care Act of 2009.
			(b)Table of
			 contentsThe table of contents of this Act is as follows:

					Sec. 1. Short title; table of contents.
					Sec. 2. Definitions.
					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.
					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.

			2.DefinitionsIn this Act:
			(1)Advance care
			 planningThe term advance care planning means the
			 process of—
				(A)determining an
			 individual’s priorities, values and goals for care in the future when the
			 individual is no longer able to express his or her wishes;
				(B)engaging family
			 members, health care proxies, and health care providers in an ongoing dialogue
			 about—
					(i)the
			 individual’s wishes for care;
					(ii)what the future
			 may hold for people with serious illnesses or injuries;
					(iii)how individuals,
			 their health care proxies, and family members want their beliefs and
			 preferences to guide care decisions; and
					(iv)the
			 steps that individuals and family members can take regarding, and the resources
			 available to help with, finances, family matters, spiritual questions, and
			 other issues that impact seriously ill or dying patients and their families;
			 and
					(C)executing and
			 updating advance directives and appointing a health care proxy.
				(2)Advance
			 directiveThe term advance directive means a living
			 will, medical directive, health care power of attorney, durable power of
			 attorney, or other written statement by a competent individual that is
			 recognized under State law and indicates the individual's wishes regarding
			 medical treatment in the event of future incompetence. Such term includes an
			 advance health care directive and a health care directive recognized under
			 State law.
			(3)CHIPThe
			 term CHIP means the program established under title XXI of the
			 Social Security Act (42 U.S.C. 1397aa et seq.).
			(4)End-of-life-careThe
			 term end-of-life care means all aspects of care of a patient with
			 a potentially fatal condition, and includes care that is focused on specific
			 preparations for an impending death.
			(5)Health care
			 power of attorneyThe term health care power of
			 attorney means a legal document that identifies a health care proxy or
			 decision maker for a patient who has the authority to act on the patient’s
			 behalf when the patient is unable to communicate his or her wishes for medical
			 care on matters that the patient specifies when he or she is competent. Such
			 term includes a durable power of attorney that relates to medical care.
			(6)Living
			 willThe term living will means a legal
			 document—
				(A)used to specify
			 the type of medical care (including any type of medical treatment, including
			 life-sustaining procedures if that person becomes permanently unconscious or is
			 otherwise dying) that an individual wants provided or withheld in the event the
			 individual cannot speak for himself or herself and cannot express his or her
			 wishes; and
				(B)that requires a
			 physician to honor the provisions of upon receipt or to transfer the care of
			 the individual covered by the document to another physician that will honor
			 such provisions.
				(7)MedicaidThe
			 term Medicaid means the program established under title XIX of the
			 Social Security Act (42 U.S.C. 1396 et seq.).
			(8)MedicareThe
			 term Medicare means the program established under title XVIII of
			 the Social Security Act (42 U.S.C. 1395 et seq.).
			(9)Orders for
			 life-sustaining treatmentThe term orders for
			 life-sustaining treatment means a process for focusing a patients'
			 values, goals, and preferences on current medical circumstances and to
			 translate such into visible and portable medical orders applicable across care
			 settings, including home, long-term care, emergency medical services, and
			 hospitals.
			(10)Palliative
			 careThe term palliative care means
			 interdisciplinary care for individuals with a life-threatening illness or
			 injury relating to pain and symptom management and psychological, social, and
			 spiritual needs and that seeks to improve the quality of life for the
			 individual and the individual's family.
			(11)SecretaryThe
			 term Secretary means the Secretary of Health and Human
			 Services.
			IAdvance Care
			 Planning
			AConsumer and
			 Provider Education
				IConsumer
			 Education
					ANational
			 initiatives
						101.Advance care
			 planning telephone hotline
							(a)In
			 GeneralNot later than January 1, 2011, the Secretary, acting
			 through the Director of the Centers for Disease Control and Prevention, shall
			 establish and operate directly, or by grant, contract, or interagency
			 agreement, a 24-hour toll-free telephone hotline to provide consumer
			 information regarding advance care planning, including—
								(1)an explanation of
			 advanced care planning and its importance;
								(2)issues to be
			 considered when developing an individual's advance care plan;
								(3)how to establish
			 an advance directive;
								(4)procedures to help
			 ensure that an individual's directives for end-of-life care are
			 followed;
								(5)Federal and
			 State-specific resources for assistance with advance care planning; and
								(6)hospice and
			 palliative care (including their respective purposes and services).
								(b)EstablishmentIn
			 carrying out the requirements under subsection (a), the Director of the Centers
			 for Disease Control and Prevention may designate an existing 24-hour toll-free
			 telephone hotline or, if no such service is available or appropriate, establish
			 a new 24-hour toll-free telephone hotline.
							102.Advance care
			 planning information clearinghouses
							(a)Expansion of
			 National Clearinghouse for Long-Term Care Information
								(1)DevelopmentNot
			 later than January 1, 2010, the Secretary shall develop an online clearinghouse
			 to provide comprehensive information regarding advance care planning.
								(2)MaintenanceThe
			 advance care planning clearinghouse, which shall be clearly identifiable and
			 available on the homepage of the Department of Health and Human Service's
			 National Clearinghouse for Long-Term Care Information website, shall be
			 maintained and publicized by the Secretary on an ongoing basis.
								(3)ContentThe
			 advance care planning clearinghouse shall include—
									(A)any relevant
			 content contained in the national public education campaign required under
			 section 104;
									(B)content
			 addressing—
										(i)an
			 explanation of advanced care planning and its importance;
										(ii)issues to be
			 considered when developing an individual's advance care plan;
										(iii)how to establish
			 an advance directive;
										(iv)procedures to
			 help ensure that an individual's directives for end-of-life care are followed;
			 and
										(v)hospice and
			 palliative care (including their respective purposes and services);
										(C)available Federal
			 and State-specific resources for assistance with advance care planning,
			 including—
										(i)contact
			 information for any State public health departments that are responsible for
			 issues regarding end-of-life care;
										(ii)contact
			 information for relevant legal service organizations, including those funded
			 under the Older Americans Act of 1965 (42 U.S.C. 3001 et seq.); and
										(iii)advance
			 directive forms for each State; and
										(D)any additional
			 information, as determined by the Secretary.
									(b)Establishment of
			 pediatric advance care planning clearinghouse
								(1)DevelopmentNot
			 later than January 1, 2011, the Secretary, in consultation with the Assistant
			 Secretary for Children and Families of the Department of Health and Human
			 Services, shall develop an online clearinghouse to provide comprehensive
			 information regarding pediatric advance care planning.
								(2)MaintenanceThe
			 pediatric advance care planning clearinghouse, which shall be clearly
			 identifiable on the homepage of the Administration for Children and Families
			 website, shall be maintained and publicized by the Secretary on an ongoing
			 basis.
								(3)ContentThe
			 pediatric advance care planning clearinghouse shall provide advance care
			 planning information specific to children with life-threatening illnesses or
			 injuries and their families.
								103.Advance care
			 planning toolkit
							(a)DevelopmentNot
			 later than July 1, 2010, the Secretary, in consultation with the Director of
			 the Centers for Disease Control and Prevention, shall develop an online advance
			 care planning toolkit.
							(b)MaintenanceThe
			 advance care planning toolkit, which shall be available in English, Spanish,
			 and any other languages that the Secretary deems appropriate, shall be
			 maintained and publicized by the Secretary on an ongoing basis and made
			 available on the following websites:
								(1)The Centers for
			 Disease Control and Prevention.
								(2)The Department of
			 Health and Human Service's National Clearinghouse for Long-Term Care
			 Information.
								(3)The Administration
			 for Children and Families.
								(c)ContentThe
			 advance care planning toolkit shall include content addressing—
								(1)common issues and
			 questions regarding advance care planning, including individuals and resources
			 to contact for further inquiries;
								(2)advance directives
			 and their uses, including living wills and durable powers of attorney;
								(3)the roles and
			 responsibilities of a health care proxy;
								(4)Federal and
			 State-specific resources to assist individuals and their families with advance
			 care planning, including—
									(A)the advance care
			 planning toll-free telephone hotline established under section 101;
									(B)the advance care
			 planning clearinghouses established under section 102;
									(C)the advance care
			 planning toolkit established under this section;
									(D)available State
			 legal service organizations to assist individuals with advance care planning,
			 including those organizations that receive funding pursuant to the Older
			 Americans Act of 1965 (42 U.S.C. 3001 et seq.); and
									(E)website links or
			 addresses for State-specific advance directive forms; and
									(5)any additional
			 information, as determined by the Secretary.
								104.National public
			 education campaign
							(a)National public education campaign
								(1)In
			 generalNot later than
			 January 1, 2011, the Secretary, acting through the Director of the Centers for
			 Disease Control and Prevention, shall, directly or through grants, contracts,
			 or interagency agreements, develop and implement a national campaign to inform
			 the public of the importance of advance care planning and of an individual's
			 right to direct and participate in their health care decisions.
								(2)Content of
			 Educational CampaignThe national public education campaign
			 established under paragraph (1) shall—
									(A)employ the use of
			 various media, including regularly televised public service
			 announcements;
									(B)provide culturally
			 and linguistically appropriate information;
									(C)be conducted
			 continuously over a period of not less than 5 years;
									(D)identify and
			 promote the advance care planning information available on the Department of
			 Health and Human Service's National Clearinghouse for Long-Term Care
			 Information website and Administration for Children and Families website, as
			 well as any other relevant Federal or State-specific advance care planning
			 resources;
									(E)raise public
			 awareness of the consequences that may result if an individual is no longer
			 able to express or communicate their health care decisions;
									(F)address the
			 importance of individuals speaking to family members, health care proxies, and
			 health care providers as part of an ongoing dialogue regarding their health
			 care choices;
									(G)address the need
			 for individuals to obtain readily available legal documents that express their
			 health care decisions through advance directives (including living wills,
			 comfort care orders, and durable powers of attorney for health care);
									(H)raise public
			 awareness regarding the availability of hospice and palliative care; and
									(I)encourage
			 individuals to speak with their physicians about their options and intentions
			 for end-of-life care.
									(3)Evaluation
									(A)In
			 GeneralNot later than July 1, 2013, the Secretary, acting
			 through the Director of the Centers for Disease Control and Prevention, shall
			 conduct a nationwide survey to evaluate whether the national campaign conducted
			 under this subsection has achieved its goal of changing public awareness,
			 attitudes, and behaviors regarding advance care planning.
									(B)Baseline
			 SurveyIn order to evaluate the effectiveness of the national
			 campaign, the Secretary shall conduct a baseline survey prior to implementation
			 of the campaign.
									(C)Reporting
			 RequirementNot later than December 31, 2013, the Secretary shall
			 report the findings of such survey, as well as any recommendations that the
			 Secretary determines appropriate regarding the need for continuation or
			 legislative or administrative changes to facilitate changing public awareness,
			 attitudes, and behaviors regarding advance care planning, to the appropriate
			 committees of the Congress.
									(b)RepealSection 4751(d) of the Omnibus Budget
			 Reconciliation Act of 1990 (42 U.S.C. 1396a note; Public Law 101–508) is
			 repealed.
							105.Update of
			 Medicare and Social Security handbooks
							(a)Medicare &
			 You handbook
								(1)In
			 generalNot later than 60 days after the date of enactment of
			 this Act, the Secretary shall update the online version of the Planning
			 Ahead section of the Medicare & You Handbook to include—
									(A)an explanation of
			 advance care planning and advance directives, including—
										(i)living
			 wills;
										(ii)health care
			 proxies; and
										(iii)after-death
			 directives;
										(B)Federal and
			 State-specific resources to assist individuals and their families with advance
			 care planning, including—
										(i)the
			 advance care planning toll-free telephone hotline established under section
			 101;
										(ii)the
			 advance care planning clearinghouses established under section 102;
										(iii)the advance care
			 planning toolkit established under section 103;
										(iv)available State
			 legal service organizations to assist individuals with advance care planning,
			 including those organizations that receive funding pursuant to the Older
			 Americans Act of 1965 (42 U.S.C. 3001 et seq.); and
										(v)website links or
			 addresses for State-specific advance directive forms; and
										(C)any additional
			 information, as determined by the Secretary.
									(2)Update of paper
			 and subsequent versionsThe Secretary shall include the
			 information described in paragraph (1) in all paper and electronic versions of
			 the Medicare & You Handbook that are published on or after the date that is
			 60 days after the date of enactment of this Act.
								(b)Social Security
			 handbookThe Commissioner of Social Security shall—
								(1)not later than 60
			 days after the date of enactment of this Act, update the online version of the
			 Social Security Handbook for beneficiaries to include the information described
			 in subsection (a)(1); and
								(2)include such
			 information in all paper and online versions of such handbook that are
			 published on or after the date that is 60 days after the date of enactment of
			 this Act.
								106.Authorization
			 of appropriationsThere is
			 authorized to be appropriated for the period of fiscal years 2010 through
			 2014—
							(1)$195,000,000 to the Secretary to carry out
			 sections 101, 102, 103, 104 and 105(a); and
							(2)$5,000,000 to the Commissioner of Social
			 Security to carry out section 105(b).
							BState and local
			 initiatives
						111.Financial
			 assistance for advance care planning
							(a)Legal assistance
			 for advance care planning
								(1)Definition of
			 recipientSection 1002(6) of the Legal Services Corporation Act
			 (42 U.S.C. 2996a(6)) is amended by striking clause (A) of  and
			 inserting subparagraph (A) or (B) of.
								(2)Advance care
			 planningSection 1006 of the Legal Services Corporation Act (42
			 U.S.C. 2996e) is amended—
									(A)in subsection
			 (a)(1)—
										(i)by
			 striking title, and (B) to make and inserting the following:
			 “title;

												(C)to
				make
												;
				and
										(ii)by
			 inserting after subparagraph (A) the following:

												(B)to provide financial assistance, and
				make grants and contracts, as described in subparagraph (A), on a competitive
				basis for the purpose of providing legal assistance in the form of advance care
				planning (as defined in section 3 of the Advance Planning and Compassionate Care Act of
				2009, and including providing information about State-specific
				advance directives, as defined in that section) for eligible clients under this
				title, including providing such planning to the family members of eligible
				clients and persons with power of attorney to make health care decisions for
				the clients; and
												;
				and
										(B)in subsection (b),
			 by adding at the end the following:

											(2)Advance care planning provided in
				accordance with subsection (a)(1)(B) shall not be construed to violate the
				Assisted Suicide Funding Restriction Act of 1997 (42 U.S.C. 14401 et
				seq.).
											.
									(3)ReportsSection
			 1008(a) of the Legal Services Corporation Act (42 U.S.C. 2996g(a)) is amended
			 by adding at the end the following: The Corporation shall require such a
			 report, on an annual basis, from each grantee, contractor, or other recipient
			 of financial assistance under section 1006(a)(1)(B)..
								(4)Authorization of
			 appropriationsSection 1010 of the Legal Services Corporation Act
			 (42 U.S.C. 2996i) is amended—
									(A)in subsection
			 (a)—
										(i)by
			 striking (a) and inserting (a)(1);
										(ii)in
			 the last sentence, by striking Appropriations for that purpose
			 and inserting the following:

												(3)Appropriations for a purpose
				described in paragraph (1) or (2)
												;
				and
										(iii)by
			 inserting before paragraph (3) (as designated by clause (ii)) the
			 following:

												(2)There are authorized to be
				appropriated to carry out section 1006(a)(1)(B), $10,000,000 for each of fiscal
				years 2010, 2011, 2012, 2013, and 2014.
												;
				and
										(B)in subsection (d),
			 by striking subsection (a) and inserting subsection
			 (a)(1).
									(5)Effective
			 dateThis subsection and the amendments made by this subsection
			 take effect July 1, 2010.
								(b)State health
			 insurance assistance programs
								(1)In
			 generalThe Secretary shall use amounts made available under
			 paragraph (3) to award grants to States for State health insurance assistance
			 programs receiving assistance under section 4360 of the Omnibus Budget
			 Reconciliation Act of 1990 to provide advance care planning services to
			 Medicare beneficiaries, personal representatives of such beneficiaries, and the
			 families of such beneficiaries. Such services shall include information
			 regarding State-specific advance directives and ways to discuss individual care
			 wishes with health care providers.
								(2)Requirements
									(A)Award of
			 grantsIn making grants under this subsection for a fiscal year,
			 the Secretary shall satisfy the following requirements:
										(i)Two-thirds of the
			 total amount of funds available under paragraph (3) for a fiscal year shall be
			 allocated among those States approved for a grant under this section that have
			 adopted the Uniform Health-Care Decisions Act drafted by the National
			 Conference of Commissioners on Uniform State Laws and approved and recommended
			 for enactment by all States at the annual conference of such commissioners in
			 1993.
										(ii)One-third of the
			 total amount of funds available under paragraph (3) for a fiscal year shall be
			 allocated among those States approved for a grant under this section that have
			 adopted a uniform form for orders regarding life sustaining treatment as
			 defined in section 1861(hhh)(5) of the Social Security Act (as amended by
			 section 211 of this Act) or a comparable approach to advance care
			 planning.
										(B)Work plan;
			 reportAs a condition of being awarded a grant under this
			 subsection, a State shall submit the following to the Secretary:
										(i)An
			 approved plan for expending grant funds.
										(ii)For
			 each fiscal year for which the State is paid grant funds under this subsection,
			 an annual report regarding the use of the funds, including the number of
			 Medicare beneficiaries served and their satisfaction with the services
			 provided.
										(C)LimitationNo
			 State shall be paid funds from a grant made under this subsection prior to July
			 1, 2010.
									(3)Authorization of
			 appropriationsThere is authorized to be appropriated to the
			 Secretary to the Centers for Medicare & Medicaid Services Program
			 Management Account, $12,000,000 for each of fiscal years 2010 through 2014 for
			 purposes of awarding grants to States under paragraph (1).
								(c)Medicaid
			 transformation grants for advance care planningSection 1903(z)
			 of the Social Security Act (42 U.S.C. 1396b(z)) is amended—
								(1)in paragraph (2),
			 by adding at the end the following new subparagraph:

										(G)Methods for
				improving the effectiveness and efficiency of medical assistance provided under
				this title by making available to individuals enrolled in the State plan or
				under a waiver of such plan information regarding advance care planning (as
				defined in section 3 of the Advance Planning
				and Compassionate Care Act of 2009), including at time of
				enrollment or renewal of enrollment in the plan or waiver, through providers,
				and through such other innovative means as the State determines
				appropriate.
										;

								(2)in paragraph (3),
			 by adding at the end the following new subparagraph:

										(D)Work plan
				required for award of advance care planning grantsPayment to a
				State under this subsection to adopt the innovative methods described in
				paragraph (2)(G) is conditioned on the State submitting to the Secretary an
				approved plan for expending the funds awarded to the State under this
				subsection.
										;
				and
								(3)in paragraph
			 (4)—
									(A)in subparagraph
			 (A)—
										(i)in
			 clause (i), by striking and at the end;
										(ii)in
			 clause (ii), by striking the period at the end and inserting ;
			 and; and
										(iii)by
			 inserting after clause (ii), the following new clause:

												(iii)$20,000,000 for
				each of fiscal years 2010 through 2014.
												;
				and
										(B)by striking
			 subparagraph (B), and inserting the following:

											(B)Allocation of fundsThe Secretary shall specify a method for
				allocating the funds made available under this subsection among States awarded
				a grant for fiscal year 2010, 2011, 2012, 2013, or 2014. Such method shall
				provide that—
												(i)100 percent of such funds for each of
				fiscal years 2010 through 2014 shall be awarded to States that design programs
				to adopt the innovative methods described in paragraph (2)(G); and
												(ii)in no event shall
				a payment to a State awarded a grant under this subsection for fiscal year 2010
				be made prior to July 1,
				2010.
												.
									(d)Advance care
			 planning community training grants
								(1)In
			 generalThe Secretary shall use amounts made available under
			 paragraph (3) to award grants to area agencies on aging (as defined in section
			 102 of the Older Americans Act of 1965 (42 U.S.C. 3002)).
								(2)Requirements
									(A)Use of
			 fundsFunds awarded to an area agency on aging under this
			 subsection shall be used to provide advance care planning education and
			 training opportunities for local aging service providers and
			 organizations.
									(B)Work plan;
			 reportAs a condition of being awarded a grant under this
			 subsection, an area agency on aging shall submit the following to the
			 Secretary:
										(i)An approved plan
			 for expending grant funds.
										(ii)For each fiscal
			 year for which the agency is paid grant funds under this subsection, an annual
			 report regarding the use of the funds, including the number of Medicare
			 beneficiaries served and their satisfaction with the services provided.
										(C)LimitationNo
			 area agency on aging shall be paid funds from a grant made under this
			 subsection prior to July 1, 2010.
									(3)Authorization of
			 appropriationsThere is authorized to be appropriated to the
			 Secretary to the Centers for Medicare & Medicaid Services Program
			 Management Account, $12,000,000 for each of fiscal years 2010 through 2014 for
			 purposes of awarding grants to area agencies on aging under paragraph
			 (1).
								(e)Nonduplication
			 of activitiesThe Secretary shall establish procedures to ensure
			 that funds made available under grants awarded under this section or pursuant
			 to amendments made by this section supplement, not supplant, existing Federal
			 funding, and that such funds are not used to duplicate activities carried out
			 under such grants or under other federally funded programs.
							112.Grants for
			 programs for orders regarding life sustaining treatment
							(a)In
			 generalThe Secretary shall make grants to eligible entities for
			 the purpose of—
								(1)establishing new programs for orders
			 regarding life sustaining treatment in States or localities;
								(2)expanding or
			 enhancing an existing program for orders regarding life sustaining treatment in
			 States or localities; or
								(3)providing a
			 clearinghouse of information on programs for orders for life sustaining
			 treatment and consultative services for the development or enhancement of such
			 programs.
								(b)Authorized
			 activitiesActivities funded through a grant under this section
			 for an area may include—
								(1)developing such a
			 program for the area that includes home care, hospice, long-term care,
			 community and assisted living residences, skilled nursing facilities, inpatient
			 rehabilitation facilities, hospitals, and emergency medical services within the
			 area;
								(2)securing
			 consultative services and advice from institutions with experience in
			 developing and managing such programs; and
								(3)expanding an
			 existing program for orders regarding life sustaining treatment to serve more
			 patients or enhance the quality of services, including educational services for
			 patients and patients' families or training of health care
			 professionals.
								(c)Distribution of
			 fundsIn funding grants under this section, the Secretary shall
			 ensure that, of the funds appropriated to carry out this section for each
			 fiscal year—
								(1)at least two-thirds are used for
			 establishing or developing new programs for orders regarding life sustaining
			 treatment; and
								(2)one-third is used for expanding or
			 enhancing existing programs for orders regarding life sustaining
			 treatment.
								(d)DefinitionsIn
			 this section:
								(1)The term
			 eligible entity includes—
									(A)an academic medical center, a medical
			 school, a State health department, a State medical association, a multi-State
			 taskforce, a hospital, or a health system capable of administering a program
			 for orders regarding life sustaining treatment for a State or locality;
			 or
									(B)any other health
			 care agency or entity as the Secretary determines appropriate.
									(2)The term
			 order regarding life sustaining treatment has the meaning given
			 such term in section 1861(hhh)(5) of the Social Security Act, as added by
			 section 211.
								(3)The term
			 program for orders regarding life sustaining treatment means, with
			 respect to an area, a program that supports the active use of orders regarding
			 life sustaining treatment in the area.
								(e)Authorization of
			 appropriationsTo carry out this section, there are authorized to
			 be appropriated such sums as may be necessary for each of the fiscal years 2009
			 through 2014.
							IIProvider
			 Education
					121.Public provider
			 advance care planning website
						(a)DevelopmentNot
			 later than January 1, 2010, the Secretary, acting through the Administrator of
			 the Centers for Medicare & Medicaid Services and the Director of the Agency
			 for Healthcare Research and Quality, shall establish a website for providers
			 under Medicare, Medicaid, the Children's Health Insurance Program, the Indian
			 Health Service (include contract providers) and other public health providers
			 on each individual's right to make decisions concerning medical care, including
			 the right to accept or refuse medical or surgical treatment, and the existence
			 of advance directives.
						(b)MaintenanceThe
			 website, shall be maintained and publicized by the Secretary on an ongoing
			 basis.
						(c)ContentThe
			 website shall include content, tools, and resources necessary to do the
			 following:
							(1)Inform providers
			 about the advance directive requirements under the health care programs
			 described in subsection (a) and other State and Federal laws and regulations
			 related to advance care planning.
							(2)Educate providers
			 about advance care planning quality improvement activities.
							(3)Provide assistance
			 to providers to—
								(A)integrate advance
			 directives into electronic health records, including oral directives;
			 and
								(B)develop and
			 disseminate advance care planning informational materials for their
			 patients.
								(4)Inform providers
			 about advance care planning continuing education requirements and
			 opportunities.
							(5)Encourage
			 providers to discuss advance care planning with their patients of all
			 ages.
							(6)Assist providers'
			 understanding of the continuum of end-of-life care services and supports
			 available to patients, including palliative care and hospice.
							(7)Inform providers
			 of best practices for discussing end-of-life care with dying patients and their
			 loved ones.
							122.Continuing
			 education for physicians and nurses
						(a)In
			 generalNot later than
			 January 1, 2012, the Secretary, acting through the Director of Health Resources
			 and Services Administration, shall develop, in consultation with health care
			 providers and State boards of medicine and nursing, a curriculum for continuing
			 education that States may adopt for physicians and nurses on advance care
			 planning and end-of-life care.
						(b)Content
							(1)In
			 generalThe continuing education curriculum developed under
			 subsection (a) for physicians and nurses shall, at a minimum, include—
								(A)a description of
			 the meaning and importance of advance care planning;
								(B)a description of
			 advance directives, including living wills and durable powers of attorney, and
			 the use of such directives;
								(C)palliative care
			 principles and approaches to care; and
								(D)the continuum of
			 end-of-life services and supports, including palliative care and
			 hospice.
								(2)Additional
			 content for physiciansThe continuing education curriculum for
			 physicians developed under subsection (a) shall include instruction on how to
			 conduct advance care planning with patients and their loved ones.
							BPortability of
			 Advance Directives; Health Information Technology
				131.Portability of
			 advance directives
					(a)MedicareSection 1866(f) of the
			 Social Security 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, 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
				opportunity to discuss issues relating to the information provided to that
				individual pursuant to subparagraph (A) with an appropriately trained
				professional.
									;
							(2)in paragraph (3), by striking a
			 written and inserting an; and
						(3)by adding at the end the following new
			 paragraph:

								(5)(A)An advance directive validly executed
				outside of the State in which such advance directive is presented by an adult
				individual to a provider of services, a Medicare Advantage organization, or a
				prepaid or eligible organization shall be given the same effect by that
				provider or organization as an advance directive validly executed under the law
				of the State in which it is presented would be given effect.
									(B)(i)The definition of an advanced directive
				shall also include actual knowledge of instructions made while an individual
				was able to express the wishes of such individual with regard to health
				care.
										(ii)For purposes of clause (i), the term
				actual knowledge means the possession of information of an
				individual’s wishes communicated to the health care provider orally or in
				writing by the individual, the individual’s medical power of attorney
				representative, the individual’s health care surrogate, or other individuals
				resulting in the health care provider’s personal cognizance of these wishes.
				Other forms of imputed knowledge are not actual knowledge.
										(C)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 portability, more deference to a patient’s wishes, or
				more latitude in determining a patient’s
				wishes.
									.
						(b)MedicaidSection 1902(w) of the
			 Social Security 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 prominent part of the
			 individual’s current medical record; and
								(ii)by inserting and if presented by 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
				opportunity to discuss issues relating to the information provided to that
				individual pursuant to subparagraph (A) with an appropriately trained
				professional.
									;
							(2)in paragraph (4), by striking a
			 written and inserting an; and
						(3)by adding at the end the following
			 paragraph:

								(6)(A)An advance directive validly executed
				outside of the State in which such advance directive is presented by an adult
				individual to a provider or organization shall be given the same effect by that
				provider or organization as an advance directive validly executed under the law
				of the State in which it is presented would be given effect.
									(B)(i)The definition of an advance directive
				shall also include actual knowledge of instructions made while an individual
				was able to express the wishes of such individual with regard to health
				care.
										(ii)For purposes of clause (i), the term
				actual knowledge means the possession of information of an
				individual’s wishes communicated to the health care provider orally or in
				writing by the individual, the individual’s medical power of attorney
				representative, the individual’s health care surrogate, or other individuals
				resulting in the health care provider’s personal cognizance of these wishes.
				Other forms of imputed knowledge are not actual knowledge.
										(C)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 portability, more deference to a patient’s wishes, or
				more latitude in determining a patient’s
				wishes.
									.
						(c)CHIPSection
			 2107(e)(1) of the Social Security Act (42 U.S.C. 1397gg(e)(1)) is
			 amended—
						(1)by redesignating
			 subparagraphs (E) through (L) as subparagraphs (D) through (M), respectively;
			 and
						(2)by inserting after
			 subparagraph (D) the following:

								(E)Section 1902(w)
				(relating to advance
				directives).
								.
						(d)Study and report regarding
			 implementation
						(1)StudyThe Secretary shall conduct a study
			 regarding the implementation of the amendments made by subsections (a) and
			 (b).
						(2)ReportNot later than 18 months after the date of
			 enactment of this Act, the Secretary shall submit to Congress a report on the
			 study conducted under paragraph (1), together with recommendations for such
			 legislation and administrative actions as the Secretary considers
			 appropriate.
						(e)Effective dates
						(1)In generalSubject to paragraph (2), the amendments
			 made by subsections (a), (b), and (c) shall apply to provider agreements and
			 contracts entered 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.)
			 and State child health plans under title XXI of such Act (42 U.S.C. 1397aa et
			 seq.), on or after such date as the Secretary 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
			 amendmentIn the case of a
			 State plan under title XIX of the Social Security
			 Act or a State child health plan under title XXI of such Act which
			 the Secretary determines requires State legislation in order for the plan to
			 meet the additional requirements imposed by the amendments made by subsections
			 (b) and (c), 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 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.
						132.State advance
			 directive registries; Driver's license advance directive notationPart P of title III of the Public Health
			 Service Act (42 U.S.C. 280g) is amended—
					(1)by redesignating
			 section 399R (as inserted by section 2 of Public Law 110–373) as section
			 399S;
					(2)by redesignating
			 section 399R (as inserted by section 3 of Public Law 110–374) as section 399T;
			 and
					(3)by adding at the
			 end the following:

							399U.State advance
				directive registries
								(a)State advance
				directive registryIn this section, the term State advance
				directive registry means a secure, electronic database that—
									(1)is available free
				of charge to residents of a State; and
									(2)stores advance
				directive documents and makes such documents accessible to medical service
				providers in accordance with Federal and State privacy laws.
									(b)Grant
				programBeginning on July 1, 2010, the Secretary, acting through
				the Director of the Centers for Disease Control and Prevention, shall award
				grants on a competitive basis to eligible entities to establish and operate,
				directly or indirectly (by competitive grant or competitive contract), State
				advance directive registries.
								(c)Eligible
				entities
									(1)In
				generalTo be eligible to receive a grant under this section, an
				entity shall—
										(A)be a State
				department of health; and
										(B)submit to the
				Director an application at such time, in such manner, and containing—
											(i)a
				plan for the establishment and operation of a State advance directive registry;
				and
											(ii)such other
				information as the Director may require.
											(2)No requirement
				of notation mechanismThe Secretary shall not require that an
				entity establish and operate a driver's license advance directive notation
				mechanism for State residents under section 399V to be eligible to receive a
				grant under this section.
									(d)Annual
				reportFor each year for which an entity receives an award under
				this section, such entity shall submit an annual report to the Director on the
				use of the funds received pursuant to such award, including the number of State
				residents served through the registry.
								(e)AuthorizationThere
				is authorized to be appropriated to carry out this section $20,000,000 for
				fiscal year 2010 and each fiscal year thereafter.
								399V.Driver's
				license advance directive notation
								(a)In
				generalBeginning July 1, 2010, the Secretary, acting through the
				Director of the Centers for Disease Control and Prevention, shall award grants
				on a competitive basis to States to establish and operate a mechanism for a
				State resident with a driver's license to include a notice of the existence of
				an advance directive for such resident on such license.
								(b)EligibilityTo
				be eligible to receive a grant under this section, a State shall—
									(1)establish and
				operate a State advance directive registry under section 399U; and
									(2)submit to the
				Director an application at such time, in such manner, and containing—
										(A)a plan that
				includes a description of how the State will—
											(i)disseminate
				information about advance directives at the time of driver’s license
				application or renewal;
											(ii)enable each State
				resident with a driver's license to include a notice of the existence of an
				advance directive for such resident on such license in a manner consistent with
				the notice on such a license indicating a driver's intent to be an organ donor;
				and
											(iii)coordinate with
				the State department of health to ensure that, if a State resident has an
				advance directive notice on his or her driver's license, the existence of such
				advance directive is included in the State registry established under section
				399U; and
											(B)any other
				information as the Director may require.
										(c)Annual
				reportFor each year for which a State receives an award under
				this section, such State shall submit an annual report to the Director on the
				use of the funds received pursuant to such award, including the number of State
				residents served through the mechanism.
								(d)AuthorizationThere
				is authorized to be appropriated to carry out this section $50,000,000 for
				fiscal year 2010 and each fiscal year
				thereafter.
								.
					133.GAO Study and
			 Report on Establishment of National Advance Directive Registry
					(a)StudyThe
			 Comptroller General of the United States shall conduct a study on the
			 feasibility of a national registry for advance directives, taking into
			 consideration the constraints created by the privacy provisions enacted as a
			 result of the Health Insurance Portability and Accountability Act of 1996
			 (Public Law 104–191).
					(b)ReportNot
			 later than 18 months after the date of enactment of this Act, the Comptroller
			 General of the United States shall submit to Congress a report on the study
			 conducted under subsection (a) together with recommendations for such
			 legislation and administrative action as the Comptroller General of the United
			 States determines to be appropriate.
					CNational Uniform
			 Policy on Advance Care Planning
				141.Study and report by the Secretary regarding
			 the establishment and implementation of a national uniform policy on advance
			 directives
					(a)Study
						(1)In generalThe Secretary, acting through the Office of
			 the Assistant Secretary for Planning and Evaluation, shall conduct a thorough
			 study of all matters relating to the establishment and implementation of a
			 national uniform policy on advance directives for individuals receiving items
			 and services under titles XVIII, XIX, or XXI of the
			 Social Security Act (42 U.S.C. 1395 et
			 seq.; 1396 et seq.; 1397aa et seq.).
						(2)Matters studiedThe matters studied by the Secretary under
			 paragraph (1) shall include issues concerning—
							(A)family satisfaction that a patient’s
			 wishes, as stated in the patient’s advance directive, were carried out;
							(B)the portability of advance directives,
			 including cases involving the transfer of an individual from one health care
			 setting to another;
							(C)immunity from civil liability and criminal
			 responsibility for health care providers that follow the instructions in an
			 individual’s advance directive that was validly executed in, and consistent
			 with the laws of, the State in which it was executed;
							(D)conditions under which an advance directive
			 is operative;
							(E)revocation of an advance directive by an
			 individual;
							(F)the criteria used by States for determining
			 that an individual has a terminal condition;
							(G)surrogate decisionmaking regarding
			 end-of-life care;
							(H)the provision of adequate palliative care
			 (as defined in paragraph (3)), including pain management;
							(I)adequate and timely referrals to hospice
			 care programs; and
							(J)the end-of-life
			 care needs of children and their families.
							(3)Palliative careFor purposes of paragraph (2)(H), the term
			 palliative care means interdisciplinary care for individuals with
			 a life-threatening illness or injury relating to pain and symptom management
			 and psychological, social, and spiritual needs and that seeks to improve the
			 quality of life for the individual and the individual’s family.
						(b)Report to congressNot later than 18 months after the date of
			 enactment of this Act, the Secretary shall submit to Congress a report on the
			 study conducted under subsection (a), together with recommendations for such
			 legislation and administrative actions as the Secretary considers
			 appropriate.
					(c)ConsultationIn conducting the study and developing the
			 report under this section, the Secretary shall consult with the Uniform Law
			 Commissioners, and other interested parties.
					IICompassionate
			 Care
			AWorkforce
			 development
				IEducation and
			 training
					201.National
			 Geriatric and Palliative Care Services CorpsSection 331 of the Public Health Service Act
			 (42 U.S.C. 254d) is amended—
						(1)by redesignating subsection (j) as
			 subsection (k); and
						(2)by inserting after
			 subsection (i), the following:

								(j)National
				Geriatric and Palliative Care Services Corps
									(1)EstablishmentNot
				later than January 1, 2012, the Secretary shall establish within the National
				Health Service Corps a National Geriatric and Palliative Care Services Corps
				(referred to in this subsection as the Corps) which shall
				consist of—
										(A)such officers of
				the Regular and Reserve Corps of the Service as the Secretary may
				designate;
										(B)such civilian
				employees of the United States as the Secretary may appoint; and
										(C)such other
				individuals who are not employees of the United States.
										(2)DutiesThe
				Corps shall be utilized by the Secretary to provide geriatric and palliative
				care services within health professional shortage areas.
									(3)Application of
				provisionsThe loan-forgiveness, scholarship, and direct
				financial incentives programs provided for under this section shall apply to
				physicians, nurses, and other health professionals (as identified by the
				Secretary) with respect to the training necessary to enable such individuals to
				become geriatric or palliative care specialists and provide geriatric and
				palliative care services in health professional shortage areas.
									(4)ReportNot
				later than 6 months prior to the date on which the Secretary establishes the
				Corps under paragraph (1), the Secretary shall submit to Congress a report
				concerning the organization of the Corps, the application process for
				membership in the Corps, and the funding necessary for the Corps (targeted by
				profession and by
				specialization).
									.
						202.Exemption of
			 palliative medicine fellowship training from Medicare graduate medical
			 education caps
						(a)Direct graduate
			 medical educationSection 1886(h)(4)(F) of the
			 Social Security Act (42 U.S.C.
			 1395ww(h)(4)(F)) is amended—
							(1)in clause (i), by
			 inserting clause (iii) and after subject to;
			 and
							(2)by adding at the
			 end the following new clause:

									(iii)Increase
				allowed for palliative medicine fellowship trainingFor cost
				reporting periods beginning on or after January 1, 2011, in applying clause
				(i), there shall not be taken into account full-time equivalent residents in
				the field of allopathic or osteopathic medicine who are in palliative medicine
				fellowship training that is approved by the Accreditation Council for Graduate
				Medical
				Education.
									.
							(b)Indirect Medical
			 EducationSection 1886(d)(5)(B) of the
			 Social Security Act (42 U.S.C.
			 1395ww(d)(5)(B)) is amended by adding at the end the following new
			 clause:

								(x)Clause (iii) of subsection (h)(4)(F)
				shall apply to clause (v) in the same manner and for the same period as such
				clause (iii) applies to clause (i) of such
				subsection.
								.
						203.Medical school
			 curricula
						(a)In
			 generalThe Secretary, in consultation with the Association of
			 American Medical Colleges, shall establish guidelines for the imposition by
			 medical schools of a minimum amount of end-of-life training as a requirement
			 for obtaining a Doctor of Medicine degree in the field of allopathic or
			 osteopathic medicine.
						(b)TrainingUnder
			 the guidelines established under subsection (a), minimum training shall
			 include—
							(1)training in how to
			 discuss and help patients and their loved ones with advance care
			 planning;
							(2)with respect to
			 students and trainees who will work with children, specialized pediatric
			 training;
							(3)training in the
			 continuum of end-of-life services and supports, including palliative care and
			 hospice;
							(4)training in how to
			 discuss end-of-life care with dying patients and their loved ones; and
							(5)medical and legal
			 issues training.
							(c)DistributionNot
			 later than January 1, 2011, the Secretary shall disseminate the guidelines
			 established under subsection (a) to medical schools.
						(d)ComplianceEffective
			 beginning not later than July 1, 2012, a medical school that is receiving
			 Federal assistance shall be required to implement the guidelines established
			 under subsection (a). A medical school that the Secretary determines is not
			 implementing such guidelines shall not be eligible for Federal
			 assistance.
						BCoverage under
			 Medicare, Medicaid, and CHIP
				ICoverage of
			 advance care planning
					211.Medicare,
			 Medicaid, and CHIP coverage
						(a)Medicare
							(1)In
			 generalSection 1861 of the Social
			 Security Act (42 U.S.C. 1395x) is amended—
								(A)in subsection
			 (s)(2)—
									(i)by
			 striking and at the end of subparagraph (DD);
									(ii)by
			 adding and at the end of subparagraph (EE); and
									(iii)by
			 adding at the end the following new subparagraph:

											(FF)advance care
				planning consultation (as defined in subsection
				(hhh)(1));
											;
				and
									(B)by adding at the
			 end the following new subsection:

										(hhh)Advance care planning consultation(1)Subject to paragraphs (3) and (4), the term
				advance care planning consultation means a consultation between
				the individual and a practitioner described in paragraph (2) regarding advance
				care planning, if, subject to subparagraphs (A) and (B) of paragraph (3), the
				individual involved has not had such a consultation within the last 5 years.
				Such consultation shall include the following:
												(A)An explanation by the practitioner of
				advance care planning, including key questions and considerations, important
				steps, and suggested people to talk to.
												(B)An explanation by the practitioner of
				advance directives, including living wills and durable powers of attorney, and
				their uses.
												(C)An explanation by the practitioner of
				the role and responsibilities of a health care proxy.
												(D)The provision by the practitioner of a
				list of national and State-specific resources to assist consumers and their
				families with advance care planning, including the national toll-free hotline,
				the advance care planning clearinghouses, and State legal service organizations
				(including those funded through the Older Americans Act).
												(E)An explanation by the practitioner of
				the continuum of end-of-life services and supports available, including
				palliative care and hospice, and benefits for such services and supports that
				are available under this title.
												(F)(i)Subject to clause (ii),
				an explanation of orders regarding life sustaining treatment or similar orders,
				which shall include—
														(I)the reasons why the development of
				such an order is beneficial to the individual and the individual’s family and
				the reasons why such an order should be updated periodically as the health of
				the individual changes;
														(II)the information needed for an individual or
				legal surrogate to make informed decisions regarding the completion of such an
				order; and
														(III)the identification of resources
				that an individual may use to determine the requirements of the State in which
				such individual resides so that the treatment wishes of that individual will be
				carried out if the individual is unable to communicate those wishes, including
				requirements regarding the designation of a surrogate decision maker (also
				known as a health care proxy).
														(ii)The Secretary may limit the
				requirement for explanations under clause (i) to consultations furnished in
				States, localities, or other geographic areas in which orders described in such
				clause have been widely adopted.
													(2)A practitioner described in this
				paragraph is—
												(A)a physician (as defined in subsection
				(r)(1)); and
												(B)a nurse practitioner or physician's
				assistant who has the authority under State law to sign orders for life
				sustaining treatments.
												(3)(A)An initial preventive
				physical examination under subsection (ww), including any related discussion
				during such examination, shall not be considered an advance care planning
				consultation for purposes of applying the 5-year limitation under paragraph
				(1).
												(B)An advance care planning consultation
				with respect to an individual shall be conducted more frequently than provided
				under paragraph (1) if there is a significant change in the health condition of
				the individual, including diagnosis of a chronic, progressive, life-limiting
				disease, a life-threatening or terminal diagnosis or life-threatening injury,
				or upon admission to a skilled nursing facility, a long-term care facility (as
				defined by the Secretary), or a hospice program.
												(4)A consultation under this subsection
				may include the formulation of an order regarding life sustaining treatment or
				a similar order.
											(5)(A)For purposes of this
				section, the term order regarding life sustaining treatment means,
				with respect to an individual, an actionable medical order relating to the
				treatment of that individual that—
													(i)is signed and dated by a physician (as
				defined in subsection (r)(1)) or another health care professional (as specified
				by the Secretary and who is acting within the scope of the professional’s
				authority under State law in signing such an order) and is in a form that
				permits it to stay with the patient and be followed by health care
				professionals and providers across the continuum of care, including home care,
				hospice, long-term care, community and assisted living residences, skilled
				nursing facilities, inpatient rehabilitation facilities, hospitals, and
				emergency medical services;
													(ii)effectively communicates the individual’s
				preferences regarding life sustaining treatment, including an indication of the
				treatment and care desired by the individual;
													(iii)is uniquely identifiable and standardized
				within a given locality, region, or State (as identified by the
				Secretary);
													(iv)is portable across care settings;
				and
													(v)may incorporate any advance directive
				(as defined in section 1866(f)(3)) if executed by the individual.
													(B)The level of treatment indicated
				under subparagraph (A)(ii) may range from an indication for full treatment to
				an indication to limit some or all or specified interventions. Such indicated
				levels of treatment may include indications respecting, among other
				items—
													(i)the intensity of medical intervention
				if the patient is pulseless, apneic, or has serious cardiac or pulmonary
				problems;
													(ii)the individual’s desire regarding
				transfer to a hospital or remaining at the current care setting;
													(iii)the use of antibiotics; and
													(iv)the use of artificially administered
				nutrition and
				hydration.
													.
								(2)PaymentSection 1848(j)(3) of the Social Security
			 Act (42 U.S.C. 1395w–4(j)(3)) is amended by inserting (2)(FF),
			 after (2)(EE),.
							(3)Frequency
			 LimitationSection 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)(1)) is
			 amended—
								(A)in paragraph
			 (1)—
									(i)in
			 subparagraph (N), by striking and at the end;
									(ii)in
			 subparagraph (O) by striking the semicolon at the end and inserting ,
			 and; and
									(iii)by
			 adding at the end the following new subparagraph:

											(P)in the case of advance care planning
				consultations (as defined in section 1861(hhh)(1)), which are performed more
				frequently than is covered under such
				section;
											;
				and
									(B)in paragraph (7),
			 by striking or (K) and inserting (K), or
			 (P).
								(4)Effective
			 DateThe amendments made by this subsection shall apply to
			 consultations furnished on or after January 1, 2011.
							(b)Medicaid
							(1)Mandatory
			 benefitSection 1902(a)(10)(A) of the Social Security Act (42
			 U.S.C. 1396a(a)(10)(A)) is amended in the matter preceding clause (i) by
			 striking and (21) and inserting , (21), and
			 (28).
							(2)Medical
			 assistanceSection 1905 of such Act (42 U.S.C. 1396d) is
			 amended—
								(A)in subsection
			 (a)—
									(i)in paragraph (27),
			 by striking and at the end;
									(ii)by redesignating
			 paragraph (28) as paragraph (29); and
									(iii)by inserting
			 after paragraph (27) the following new paragraph:

											(28)advance care
				planning consultations (as defined in subsection
				(y));
											;
				and
									(B)by adding at the
			 end the following:

										(y)(1)For purposes of
				subsection (a)(28), the term advance care planning consultation
				means a consultation between the individual and a practitioner described in
				paragraph (2) regarding advance care planning, if, subject to paragraph (3),
				the individual involved has not had such a consultation within the last 5
				years. Such consultation shall include the following:
												(A)An explanation by the practitioner of
				advance care planning, including key questions and considerations, important
				steps, and suggested people to talk to.
												(B)An explanation by the practitioner of
				advance directives, including living wills and durable powers of attorney, and
				their uses.
												(C)An explanation by the practitioner of
				the role and responsibilities of a health care proxy.
												(D)The provision by the practitioner of a
				list of national and State-specific resources to assist consumers and their
				families with advance care planning, including the national toll-free hotline,
				the advance care planning clearinghouses, and State legal service organizations
				(including those funded through the Older Americans Act).
												(E)An explanation by the practitioner of
				the continuum of end-of-life services and supports available, including
				palliative care and hospice, and benefits for such services and supports that
				are available under this title.
												(F)(i)Subject to clause (ii),
				an explanation of orders for life sustaining treatments or similar orders,
				which shall include—
														(I)the reasons why the development of
				such an order is beneficial to the individual and the individual’s family and
				the reasons why such an order should be updated periodically as the health of
				the individual changes;
														(II)the information needed for an individual or
				legal surrogate to make informed decisions regarding the completion of such an
				order; and
														(III)the identification of resources
				that an individual may use to determine the requirements of the State in which
				such individual resides so that the treatment wishes of that individual will be
				carried out if the individual is unable to communicate those wishes, including
				requirements regarding the designation of a surrogate decision maker (also
				known as a health care proxy).
														(ii)The Secretary may limit the
				requirement for explanations under clause (i) to consultations furnished in
				States, localities, or other geographic areas in which orders described in such
				clause have been widely adopted.
													(2)A practitioner described in this
				paragraph is—
												(A)a physician (as defined in section
				1861(r)(1)); and
												(B)a nurse practitioner or physician's
				assistant who has the authority under State law to sign orders for life
				sustaining treatments.
												(3)An advance care planning consultation
				with respect to an individual shall be conducted more frequently than provided
				under paragraph (1) if there is a significant change in the health condition of
				the individual including diagnosis of a chronic, progressive, life-limiting
				disease, a life-threatening or terminal diagnosis or life-threatening injury,
				or upon admission to a nursing facility, a long-term care facility (as defined
				by the Secretary), or a hospice program.
											(4)A
				consultation under this subsection may include the formulation of an order
				regarding life sustaining treatment or a similar order.
											(5)For purposes of this subsection, the term
				orders regarding life sustaining treatment has the meaning given
				that term in section
				1861(hhh)(5).
											.
								(c)CHIP
							(1)Child health
			 assistanceSection 2110(a) of the Social Security Act (42 U.S.C.
			 1397jj) is amended—
								(A)by redesignating
			 paragraph (28) as paragraph (29); and
								(B)by inserting after
			 paragraph (27), the following:

										(28)Advance care
				planning consultations (as defined in section
				1905(y)).
										.
								(2)Mandatory
			 coverage
								(A)In
			 generalSection 2103 of such Act (42 U.S.C. 1397cc), is
			 amended—
									(i)in
			 subsection (a), in the matter preceding paragraph (1), by striking and
			 (7) and inserting (7), and (9); and
									(ii)in
			 subsection (c), by adding at the end the following:

											(9)End-of-life
				careThe child health assistance provided to a targeted
				low-income child shall include coverage of advance care planning consultations
				(as defined in section 1905(y) and at the same payment rate as the rate that
				would apply to such a consultation under the State plan under title
				XIX).
											.
									(B)Conforming
			 amendmentSection 2102(a)(7)(B) of such Act (42 U.S.C.
			 1397bb(a)(7)(B)) is amended by striking section 2103(c)(5) and
			 inserting paragraphs (5) and (9) of section 2103(c).
								(d)Definition of
			 advance directive under Medicare, Medicaid, and CHIP
							(1)MedicareSection
			 1866(f)(3) of the Social Security Act (42 U.S.C. 1395cc(f)(3)) is amended by
			 striking means and all that follows through the period and
			 inserting means a living will, medical directive, health care power of
			 attorney, durable power of attorney, or other written statement by a competent
			 individual that is recognized under State law and indicates the individual's
			 wishes regarding medical treatment in the event of future incompetence. Such
			 term includes an advance health care directive and a health care directive
			 recognized under State law..
							(2)Medicaid and
			 chipSection 1902(w)(4) of such Act (42 U.S.C. 1396a(w)(4)) is
			 amended by striking means and all that follows through the
			 period and inserting means a living will, medical directive, health care
			 power of attorney, durable power of attorney, or other written statement by a
			 competent individual that is recognized under State law and indicates the
			 individual's wishes regarding medical treatment in the event of future
			 incompetence. Such term includes an advance health care directive and a health
			 care directive recognized under State law..
							(e)Effective
			 dateThe amendments made by this section take effect January 1,
			 2010.
						IIHospice
					221.Adoption of
			 MedPAC hospice payment methodology recommendationsSection
			 1814(i) of the Social Security Act (42 U.S.C. 1395f(i)) is amended by adding at
			 the end the following new paragraph:

							(6)(A)The Secretary shall conduct an evaluation
				of the recommendations of the Medicare Payment Commission for reforming the
				hospice care benefit under this title that are contained in chapter 6 of the
				Commission's report entitled Report to Congress: Medicare Payment Policy
				(March 2009), including the impact that such recommendations if
				implemented would have on access to care and the quality of care. In conducting
				such evaluation, the Secretary shall take into account data collected in
				accordance with section 263(b) of the Advance
				Planning and Compassionate Care Act of 2009.
								(B)Based on the results of the
				examination conducted under subparagraph (A), the Secretary shall make
				appropriate refinements to the recommendations described in subparagraph (A).
				Such refinements shall take into account—
									(i)the impact on patient populations
				with longer that average lengths of stay;
									(ii)the impact on populations with
				shorter that average lengths of stay; and
									(iii)the utilization patterns of
				hospice providers in underserved areas, including rural hospices.
									(C)Not later than January 1, 2013, the
				Secretary shall submit to Congress a report that contains a detailed
				description of—
									(i)the refinements determined
				appropriate by the Secretary under subparagraph (B);
									(ii)the revisions that the Secretary
				will implement through regulation under this title pursuant to subparagraph
				(D); and
									(iii)the revisions that the Secretary
				determines require additional legislative action by Congress.
									(D)(i)The Secretary shall implement the
				recommendations described in subparagraph (A), as refined under subparagraph
				(B).
									(ii)Subject to clause (iii), the
				implementation of such recommendations shall apply to hospice care furnished on
				or after January 1, 2014.
									(iii)The Secretary shall establish an
				appropriate transition to the implementation of such recommendations.
									(E)For purposes of carrying out the
				provisions of this paragraph, the Secretary shall provide for the transfer,
				from the Federal Hospital Insurance Trust Fund under section 1817, of such sums
				as may be necessary to the Centers for Medicare & Medicaid Services Program
				Management
				Account.
								.
					222.Removing
			 hospice inpatient days in setting per diem rates for critical access
			 hospitalsSection 1814(l) of
			 the Social Security Act (42 U.S.C. 1395f(l)), as amended by section 4102(b)(2)
			 of the HITECH Act (Public Law 111–5), is amended by adding at the end the
			 following new paragraph:

							(6)For cost reporting periods beginning on or
				after January 1, 2011, the Secretary shall remove Medicare-certified hospice
				inpatient days from the calculation of per diem rates for inpatient critical
				access hospital services.
							.

					223.Hospice
			 payments for dual eligible individuals residing in long-term care
			 facilities
						(a)In
			 generalSection 1888 of the
			 Social Security Act (42 U.S.C. 1395yy) is amended by adding at the end the
			 following new subsection:

								(f)Payments for
				dual eligible individuals residing in long-term care facilitiesFor cost reporting periods beginning on or
				after January 1, 2011, the Secretary, acting through the Administrator of the
				Centers for Medicare & Medicaid Services, shall establish procedures under
				which payments for room and board under the State Medicaid plan with respect to
				an applicable individual are made directly to the long-term care facility (as
				defined by the Secretary for purposes of title XIX) the individual is a
				resident of. For purposes of the preceding sentence, the term applicable
				individual means an individual who is entitled to or enrolled for
				benefits under part A or enrolled for benefits under part B and is eligible for
				medical assistance for hospice care under a State plan under title
				XIX.
								.
						(b)State plan
			 requirement
							(1)In
			 generalSection 1902(a) of the Social Security Act (42 U.S.C.
			 1396a(a)) is amended—
								(A)in paragraph (72),
			 by striking and at the end;
								(B)in paragraph (73),
			 by striking the period at the end and inserting ; and;
			 and
								(C)by inserting after
			 paragraph (73) the following new paragraph:

										(74)provide that the
				State will make payments for room and board with respect to applicable
				individuals in accordance with section
				1888(f).
										.
								(2)Effective
			 date
								(A)In
			 generalExcept as provided in subparagraph (B), the amendments
			 made by paragraph (1) take effect on January 1, 2011.
								(B)Extension of
			 effective date for state law amendmentIn the case of a State
			 plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) which
			 the Secretary determines requires State legislation in order for the plan to
			 meet the additional requirements imposed by the amendments made by paragraph
			 (1), 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 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.
								224.Delineation of
			 respective care responsibilities of hospice programs and long-term care
			 facilitiesSection 1888 of the
			 Social Security Act (42 U.S.C. 1395yy), as amended by section 223(a), is
			 amended by adding at the end the following new subsection:

							(g)Delineation of
				respective care responsibilities of hospice programs and long-term care
				facilitiesNot later than July 1, 2011, the Secretary, acting
				through the Administrator of the Centers for Medicare & Medicaid Services,
				shall delineate and enforce the respective care responsibilities of hospice
				programs and long-term care facilities (as defined by the Secretary for
				purposes of title XIX) with respect to individuals residing in such facilities
				who are furnished hospice
				care.
							.
					225.Adoption of
			 MedPAC hospice program eligibility certification and recertification
			 recommendationsIn accordance
			 with the recommendations of the Medicare Payment Advisory Commission contained
			 in the March 2009 report entitled Report to Congress: Medicare Payment
			 Policy, section 1814(a)(7) of the Social Security Act (42 U.S.C.
			 1395f(a)(7)) is amended—
						(1)in subparagraph (B), by striking
			 and at the end; and
						(2)by adding at the end the following new
			 subparagraph:

								(D)on or after January 1, 2011—
									(i)a hospice physician or advance practice
				nurse visits the individual to determine continued eligibility of the
				individual for hospice care prior to the 180th day recertification and each
				subsequent recertification under subparagraph (A)(ii) and attests that such
				visit took place (in accordance with procedures established by the Secretary,
				in consultation with the Administrator of the Centers for Medicare &
				Medicaid Services); and
									(ii)any certification
				or recertification under subparagraph (A) includes a brief narrative describing
				the clinical basis for the individual’s prognosis (in accordance with
				procedures established by the Secretary, in consultation with the Administrator
				of the Centers for Medicare & Medicaid Services);
				and
									.
						226.Concurrent care
			 for children
						(a)Permitting
			 Medicare hospice beneficiaries 18 years of age or younger To receive curative
			 care
							(1)In generalSection 1812 of the Social Security Act (42
			 U.S.C. 1395d) is amended—
								(A)in subsection (a)(4), by inserting
			 (subject to the second sentence of subsection (d)(2)(A)) after
			 in lieu of certain other benefits; and
								(B)in subsection (d)—
									(i)in paragraph (1), by inserting  ,
			 subject to the second sentence of paragraph (2)(A),  after
			 instead; and
									(ii)in paragraph (2)(A), by adding at the end
			 the following new sentence: Clause (ii)(I) shall not apply to an
			 individual who is 18 years of age or younger.
									(2)Conforming amendmentSection 1862(a)(1)(C) of the Social
			 Security Act (42 U.S.C. 1395y(a)(1)(C)) is amended inserting subject to
			 the second sentence of section 1812(d)(2)(A),  after hospice
			 care,.
							(b)Application to
			 Medicaid and CHIP
							(1)MedicaidSection
			 1905(o)(1)(A) of the Social Security Act (42 U.S.C. 1395d(o)(1)(A)) is amended
			 by inserting (subject, in the case of an individual who is a child, to
			 the second sentence of such section) after section
			 1812(d)(2)(A).
							(2)CHIPSection
			 2110(a)(23) of the Social Security Act (42 U.S.C. 1397jj(a)(23)) is amended by
			 inserting (concurrent, in the case of an individual who is a child, with
			 care related to the treatment of the individual's condition with respect to
			 which a diagnosis of terminal illness has been made) after
			 hospice care.
							(c)Effective
			 dateThe amendments made by
			 this section shall apply to items and services furnished on or after January 1,
			 2011.
						227.Making hospice
			 a required benefit under Medicaid and CHIP
						(a)Mandatory
			 benefit
							(1)Medicaid
								(A)In
			 generalSection 1902(a)(10)(A) of the Social Security Act (42
			 U.S.C. 1396a(a)(10)(A)), as amended by section 211(b)(1), is amended in the
			 matter preceding clause (i) by inserting (18), after
			 (17),.
								(B)Conforming
			 amendmentSection 1902(a)(10)(C) of such Act (42 U.S.C.
			 1396a(a)(10)(C)) is amended—
									(i)in
			 clause (iii)—
										(I)in subclause (I),
			 by inserting and hospice care after ambulatory
			 services; and
										(II)in subclause
			 (II), by inserting and hospice care after delivery
			 services; and
										(ii)in
			 clause (iv), by inserting and (18) after
			 (17).
									(2)CHIPSection
			 2103(c)(9) of such Act (42 U.S.C. 1397cc(c)(9)), as added by section
			 211(c)(2)(A), is amended by inserting and hospice care before
			 the period.
							(b)Effective
			 dateThe amendments made
			 subsection (a) take effect on January 1, 2011.
						228.Medicare
			 Hospice payment model demonstration projects
						(a)EstablishmentNot
			 later than July 1, 2012, the Secretary, acting through the Administrator of the
			 Centers for Medicare & Medicaid Services and the Director of the Agency for
			 Healthcare Research and Quality, shall conduct demonstration projects to
			 examine ways to improve how the Medicare hospice care benefit predicts disease
			 trajectory. Projects shall include the following models:
							(1)Models that better
			 and more appropriately care for, and transition as needed, patients in their
			 last years of life who need palliative care, but do not qualify for hospice
			 care under the Medicare hospice eligibility criteria.
							(2)Models that better
			 and more appropriately care for long-term patients who are not recertified in
			 hospice but still need palliative care.
							(3)Any other models
			 determined appropriate by the Secretary.
							(b)Waiver authorityThe Secretary may waive compliance of such
			 requirements of titles XI and XVIII of the Social
			 Security Act as the Secretary determines necessary to conduct the
			 demonstration projects under this section.
						(c)ReportsThe Secretary shall submit to Congress
			 periodic reports on the demonstration projects conducted under this
			 section.
						229.MedPAC studies
			 and reports
						(a)Study and report
			 regarding an alternative payment methodology for hospice care under the
			 Medicare program
							(1)StudyThe
			 Medicare Payment Advisory Commission (in this section referred to as the
			 Commission) shall conduct a study on the establishment of a
			 reimbursement system for hospice care furnished under the Medicare program that
			 is based on diagnoses. In conducting such study, the Commission shall use data
			 collected under new provider data requirements. Such study shall include an
			 analysis of the following:
								(A)Whether such a
			 reimbursement system better meets patient needs and better corresponds with
			 provider resource expenditures than the current system.
								(B)Whether such a
			 reimbursement system improves quality, including facilitating standardization
			 of care toward best practices and diagnoses-specific clinical pathways in
			 hospice.
								(C)Whether such a
			 reimbursement system could address concerns about the blanket 6-month terminal
			 prognosis requirement in hospice.
								(D)Whether such a
			 reimbursement system is more cost effective than the current system.
								(E)Any other areas
			 determined appropriate by the Commission.
								(2)ReportNot
			 later than June 15, 2013, the Commission shall submit to Congress a report on
			 the study conducted under subsection (a) together with recommendations for such
			 legislation and administrative action as the Commission determines
			 appropriate.
							(b)Study and report
			 regarding rural hospice transportation costs under the Medicare
			 program
							(1)StudyThe
			 Commission shall conduct a study on rural Medicare hospice transportation
			 mileage to determine potential Medicare reimbursement changes to account for
			 potential higher costs.
							(2)ReportNot
			 later than June 15, 2013, the Commission shall submit to Congress a report on
			 the study conducted under subsection (a) together with recommendations for such
			 legislation and administrative action as the Commission determines
			 appropriate.
							(c)Evaluation of
			 reimbursement disincentives To elect medicare hospice within the medicare
			 skilled nursing facility benefit
							(1)StudyThe
			 Commission shall conduct a study to determine potential Medicare reimbursement
			 changes to remove Medicare reimbursement disincentives for patients in a
			 skilled nursing facility who want to elect hospice.
							(2)ReportNot
			 later than June 15, 2013, the Commission shall submit to Congress a report on
			 the study conducted under subsection (a) together with recommendations for such
			 legislation and administrative action as the Commission determines
			 appropriate.
							230.HHS
			 Evaluations
						(a)Evaluation of
			 access to hospice and hospital-based palliative care
							(1)EvaluationThe Secretary, acting through the
			 Administrator of the Health Resources and Services Administration, shall
			 conduct an evaluation of geographic areas and populations underserved by
			 hospice and hospital-based palliative care to identify potential barriers to
			 access.
							(2)ReportNot later than December 31, 2012, the
			 Secretary shall report to Congress, on the evaluation conducted under
			 subsection (a) together with recommendations for such legislation and
			 administrative action as the Secretary determines appropriate to address
			 barriers to access to hospice and hospital-based palliative care.
							(b)Evaluation of
			 awareness and use of hospice respite care under Medicare, Medicaid, and
			 CHIP
							(1)EvaluationThe Secretary, acting through the Director
			 of the Centers for Medicare & Medicaid Services, shall evaluate the
			 awareness and use of hospice respite care by informal caregivers of
			 beneficiaries under Medicare, Medicaid, and CHIP.
							(2)ReportNot later than December 31, 2010, the
			 Secretary shall report to Congress, on the evaluation conducted under
			 subsection (a) together with recommendations for such legislation and
			 administrative action as the Secretary determines appropriate to increase
			 awareness or use of hospice respite care under Medicare, Medicaid, and
			 CHIP.
							CQuality
			 Improvement
				241.Patient
			 satisfaction surveysNot later
			 than January 1, 2012, the Secretary, acting through the Administrator of the
			 Centers for Medicare & Medicaid Services, shall establish a mechanism
			 for—
					(1)collecting information from patients (or
			 their health care proxies or families members in the event patients are unable
			 to speak for themselves) in relevant provider settings regarding their care at
			 the end of life; and
					(2)incorporating such information in a timely
			 manner into mechanisms used by the Administrator to provide quality of care
			 information to consumers, including the Hospital Compare and Nursing Home
			 Compare websites maintained by the Administrator.
					242.Development of
			 core end-of-life care quality measures across each relevant provider
			 setting
					(a)In
			 generalThe Secretary, acting
			 through the Administrator of the Agency for Healthcare Research and Quality (in
			 this section referred to as the Administrator) and in
			 consultation with the Director of the National Institutes of Health, shall
			 require specific end-of-life quality measures for each relevant provider
			 setting, as identified by the Administrator, in accordance with the
			 requirements of subsection (b).
					(b)RequirementsFor purposes of subsection (a), the
			 requirements specified in this subsection are the following:
						(1)Selection of the
			 specific measure or measures for an identified provider setting shall
			 be—
							(A)based on an
			 assessment of what is likely to have the greatest positive impact on quality of
			 end-of-life care in that setting; and
							(B)made in
			 consultation with affected providers and public and private organizations, that
			 have developed such measures.
							(2)The measures may
			 be structure-oriented, process-oriented, or outcome-oriented, as determined
			 appropriate by the Administrator.
						(3)The Administrator
			 shall ensure that reporting requirements related to such measures are imposed
			 consistent with other applicable laws and regulations, and in a manner that
			 takes into account existing measures, the needs of patient populations, and the
			 specific services provided.
						(4)Not later than—
							(A)April 1, 2011, the Secretary shall
			 disseminate the reporting requirements to all affected providers; and
							(B)April 1, 2012, initial reporting relating
			 to the measures shall begin.
							243.Accreditation
			 of Hospital-Based Palliative Care Programs
					(a)In
			 GeneralThe Secretary, acting through the Director of the Agency
			 for Healthcare Research and Quality, shall designate a public or private
			 agency, entity, or organization to develop requirements, standards, and
			 procedures for accreditation of hospital-based palliative care programs.
					(b)ReportingNot
			 later than January 1, 2012, the Secretary shall prepare and submit a report to
			 Congress on the proposed accreditation process for hospital-based palliative
			 care programs.
					(c)AccreditationNot
			 later than July 1, 2012, the Secretary shall—
						(1)establish and
			 promulgate standards and procedures for accreditation of hospital-based
			 palliative care programs; and
						(2)designate an
			 agency, entity, or organization that shall be responsible for certifying such
			 programs in accordance with the standards established under paragraph
			 (1).
						(d)DefinitionsFor
			 the purposes of this section:
						(1)The term
			 hospital-based palliative care program means a hospital-based
			 program that is comprised of an interdisciplinary team that specializes in
			 providing palliative care services and consultations in a variety of health
			 care settings, including hospitals, nursing homes, and home and community-based
			 services.
						(2)The term
			 interdisciplinary team means a group of health care professionals
			 (consisting of, at a minimum, a doctor, a nurse, and a social worker) that have
			 received specialized training in palliative care.
						244.Survey and data
			 requirements for all Medicare participating hospice programs
					(a)Hospice
			 surveysSection 1861(dd) of
			 the Social Security Act (42 U.S.C. 1395x(dd)) is amended by adding at the end
			 the following new paragraph:

							(6)In accordance with the recommendations of
				the Medicare Payment Advisory Commission contained in the March 2009 report
				entitled Report to Congress: Medicare Payment Policy, the
				Secretary shall establish, effective July 1, 2010, the following survey
				requirements for hospice programs:
								(A)Any hospice program seeking initial
				certification under this title on or after that date shall be subject to an
				initial survey by an appropriate State or local agency, or an approved
				accreditation agency, not later than 6 months after the program first seeks
				such certification.
								(B)All hospice programs certified for
				participation under this title shall be subject to a standard survey by an
				appropriate State or local agency, or an approved accreditation agency, at
				least every 3 years after initially being so
				certified.
								.
					(b)Required hospice
			 resource inputs dataSection 1861(dd) of the Social Security Act
			 (42 U.S.C. 1395x(dd)), as amended by subsection (a), is amended—
						(1)in paragraph
			 (3)—
							(A)in subparagraph
			 (F), by striking and at the end;
							(B)by redesignating
			 subparagraph (G) as subparagraph (H); and
							(C)by inserting after
			 subparagraph (F) the following new subparagraph:

									(G)to comply with the reporting
				requirements under paragraph (7); and
									;
				and
							(2)by adding at the
			 end the following new paragraph:

								(7)(A)In accordance with the recommendations of
				the Medicare Payment Advisory Commission for additional data (as contained in
				the March 2009 report entitled Report to Congress: Medicare Payment
				Policy), beginning January 1, 2011, a hospice program shall report to
				the Secretary, in such form and manner, and at such intervals, as the Secretary
				shall require, the following data with respect to each patient visit:
										(i)Visit type (such as admission, routine,
				emergency, education for family, other).
										(ii)Visit length.
										(iii)Professional or paraprofessional
				disciplines involved in the visit, including nurse, social worker, home health
				aide, physician, nurse practitioner, chaplain or spiritual counselor,
				counselor, dietician, physical therapist, occupational therapist, speech
				language pathologist, music or art therapist, and including bereavement and
				support services provided to a family after a patient’s death.
										(iv)Drugs and other therapeutic interventions
				provided.
										(v)Home medical equipment and other medical
				supplies provided.
										(B)In collecting the data required under
				subparagraph (A), the Secretary shall ensure that the data are reported in a
				manner that allows for summarized cross-tabulations of the data by patients’
				terminal diagnoses, lengths of stay, age, sex, and
				race.
									.
						DAdditional
			 reports, research, and evaluations
				251.National Center
			 on Palliative and End-of-Life CarePart E of title IV of the Public Health
			 Service Act (42 U.S.C. 287 et seq.) is amended by adding at the end the
			 following:

						7National Center on
				Palliative and End-of-Life Care
							485J.National
				Center On Palliative and End-of-Life Care
								(a)EstablishmentNot
				later than July 1, 2011, there shall be established within the National
				Institutes of Health, a National Center on Palliative and End-of-Life Care
				(referred to in this section as the Center).
								(b)PurposeThe
				general purpose of the Center is to conduct and support research relating to
				palliative and end-of-life care interventions and approaches.
								(c)ActivitiesThe
				Center shall—
									(1)develop and
				continuously update a research agenda with the goal of—
										(A)providing a better
				biomedical understanding of the end of life; and
										(B)improving the
				quality of care and life at the end of life; and
										(2)provide funding
				for peer-review-selected extra- and intra-mural research that includes the
				evaluation of existing, and the development of new, palliative and end-of-life
				care interventions and
				approaches.
									.
				252.National
			 Mortality Followback Survey
					(a)In
			 generalNot later than December 31, 2010, and annually
			 thereafter, the Secretary, acting through the Director of the Centers for
			 Disease Control and Prevention, shall renew and conduct the National Mortality
			 Followback Survey (referred to in this section as the Survey) to
			 collect data on end-of-life care.
					(b)PurposeThe
			 purpose of the Survey shall be to gain a better understanding of current
			 end-of-life care in the United States.
					(c)Questions
						(1)In
			 generalIn conducting the Survey, the Director of the Centers for
			 Disease Control and Prevention shall, at a minimum, include the following
			 questions with respect to the loved one of a respondent:
							(A)Did he or she have
			 an advance directive, and if so, when it was completed.
							(B)Did he or she have
			 an order for life-sustaining treatment, and if so, when was it
			 completed.
							(C)Did he or she have
			 a durable power of attorney, and if so, when it was completed.
							(D)Had he or she
			 discussed his or her wishes with loved ones, and if so, when.
							(E)Had he or she
			 discussed his or her wishes with his or her physician, and if so, when.
							(F)In the opinion of
			 the respondent, was he or she satisfied with the care he or she received in the
			 last year of life and in the last week of life.
							(G)Was he or she
			 cared for by hospice, and if so, when.
							(H)Was he or she
			 cared for by palliative care specialists, and if so, when.
							(I)Did he or she
			 receive effective pain management (if needed).
							(J)What was the
			 experience of the main caregiver (including if such caregiver was the
			 respondent), and whether he or she received sufficient support in this
			 role.
							(2)Additional
			 questionsAdditional questions to be asked during the Survey
			 shall be determined by the Director of the Centers for Disease Control and
			 Prevention on an ongoing basis with input from relevant research
			 entities.
						253.Demonstration
			 Projects for Use of Telemedicine Services in Advance Care Planning
					(a)In
			 GeneralNot later than July 1, 2013, the Secretary shall
			 establish a demonstration program to reimburse eligible entities for costs
			 associated with the use of telemedicine services (including equipment and
			 connection costs) to provide advance care planning consultations with
			 geographically distant physicians and their patients.
					(b)DurationThe
			 demonstration project under this section shall be conducted for at least a
			 3-year period.
					(c)DefinitionsFor
			 purposes of this section:
						(1)The term
			 eligible entity means a physician or an advance practice nurse who
			 provides services pursuant to a hospital-based palliative care program (as
			 defined in section 262(d)(1)).
						(2)The term
			 geographically distant has the meaning given that term by the
			 Secretary for purposes of conducting the demonstration program established
			 under this section.
						(3)The term
			 telemedicine services means a service or consultation provided via
			 telecommunication equipment that allows an eligible entity to exchange or
			 discuss medical information with a patient or a health care professional at a
			 separate location through real-time videoconferencing, or a similar format, for
			 the purpose of providing health care diagnosis and treatment.
						(d)FundingThere
			 are authorized to be appropriated to the Secretary such sums as may be
			 necessary to carry out this section.
					254.Inspector
			 General investigation of fraud and abuseIn accordance with the recommendations of
			 the Medicare Payment Advisory Commission for additional data (as contained in
			 the March 2009 report entitled Report to Congress: Medicare Payment
			 Policy), the Secretary shall direct the Office of the Inspector General
			 of the Department of Health and Human Services to investigate, not later than
			 January 1, 2012, the following with respect to hospice benefit under Medicare,
			 Medicaid, and CHIP:
					(1)The prevalence of financial relationships
			 between hospices and long-term care facilities, such as nursing facilities and
			 assisted living facilities, that may represent a conflict of interest and
			 influence admissions to hospice.
					(2)Differences in patterns of nursing home
			 referrals to hospice.
					(3)The appropriateness of enrollment practices
			 for hospices with unusual utilization patterns (such as high frequency of very
			 long stays, very short stays, or enrollment of patients discharged from other
			 hospices).
					(4)The appropriateness of hospice marketing
			 materials and other admissions practices and potential correlations between
			 length of stay and deficiencies in marketing or admissions practices.
					255.GAO study and report
			 on provider adherence to advance directivesNot later than January 1, 2012, the
			 Comptroller General of the United States shall conduct a study of the extent to
			 which providers comply with advance directives under the Medicare and Medicaid
			 programs and shall submit a report to Congress on the results of such study,
			 together with such recommendations for administrative or legislative changes as
			 the Comptroller General determines appropriate.