[Congressional Record Volume 155, Number 79 (Thursday, May 21, 2009)]
[Senate]
[Pages S5862-S5872]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. REID (for Mr. Rockefeller (for himself, Ms. Collins, Mr. 
        Kohl, Mr. Wyden, and Mr. Carper)):
  S. 1150. A bill to improve end-of-life care; to the Committee on 
Finance.
  Mr. ROCKEFELLER. Mr. President, I rise today with my friends and 
colleagues--Senators Collins, Kohl, Wyden and Carper--to introduce the 
Advance Planning and Compassionate Care Act of 2009, comprehensive 
legislation that recognizes the critical importance of advance care 
planning and quality end-of-life care. Senator Collins and I have 
worked on this legislation for over a decade--with the ultimate goal of 
one day passing comprehensive end-of-life care legislation. We are 
encouraged by the prospect of comprehensive health reform this year and 
believe that it is absolutely critical that end-of-life care provisions 
be included.
  In preparation for the impending health reform debate, Senator 
Collins and I decided last year that it was time to update our Advance 
Planning and Compassionate Care Act to incorporate all of the best 
ideas out there on improving end-of-life care--including new and 
innovative approaches being implemented in the states, approaches 
suggested by scholars in this field, and recommendations based on our 
own experiences with loved ones facing the end of life. This new and 
improved bill is truly a labor of love and we are certainly hopeful 
that we can finally get something comprehensive and meaningful done for 
the millions of individuals and families faced with the agonizing 
issues surrounding the end of life.
  A modern health care delivery system is well within our reach and 
something that we can start to achieve this year. A critical component 
of a modernized health system is the ability to address the health care 
needs of patients across the life-span--especially at the end of life. 
Death is a serious, personal, and complicated part of the life cycle. 
Yet, care at the end of life is eventually relevant to everyone. 
Americans deserve end-of-life care that is effective in providing 
information about diagnosis and prognosis, integrating appropriate 
support services, fulfilling individual wishes, and avoiding 
unnecessary disputes.
  The bitter dispute that played out publicly for Terri Schiavo and her 
family is an agonizing experience that countless other families quietly 
face over the care of a loved one because clear advance directives are 
not in place. End-of-life care is a very delicate, yet important, issue 
and we must act to ensure that all Americans have the dignity and 
comfort they deserve at the end of life. Services should be available 
to help patients and their families with the medical, psychological, 
spiritual, and practical issues surrounding death.
  Most people want to discuss advance directives when they are healthy 
and they want their families involved in the process. Yet, the vast 
majority of Americans have not completed an advance directive 
expressing their final wishes. In 2007, RAND conducted a comprehensive 
review of academic literature relating to end-of-life decision-making. 
This review found that only 18 to 30 percent of Americans have 
completed some type of advance directive expressing their end-of-life 
wishes. RAND also found that acutely ill individuals, for whom these 
decisions are particularly relevant, complete advance directives at 
only slightly higher rates--35 percent of dialysis patients and 32 
percent of Chronic Obstructive Pulmonary Disease, COPD, patients. 
Perhaps most alarmingly, between 65 and 76 percent of physicians whose 
patients had an advance directive were unaware of its existence.
  In its present form, end-of-life planning and care for most Americans 
is perplexing, disjointed, and lacking an active dialogue. In its 1997 
report entitled Approaching Death: Improving Care at the End of Life, 
the Institute of Medicine found several barriers to effective advance 
planning and end-of-life care that still persist today.
  In addition to the substantial burden of suffering experienced by 
many at the end of life, there are also significant financial 
consequences for family members and society as a whole that stem from 
ineffective end-of-life care. According to one Federal evaluation, 80 
percent of all deaths occur in hospitals--the most costly setting to 
deliver care--even though most people would prefer to die at home. 
Current studies indicate that around 25 percent of all Medicare 
spending occurs in the last year of life. Largely because of their 
poorer health status, dually eligible beneficiaries have Medicare costs 
that are about 1.5 times that of other Medicare beneficiaries. Research 
also shows significant variation in expenditures at the end-of-life by 
geography and hospital, without evidence that greater expenditures are 
associated with better outcomes or satisfaction.
  We must find ways to improve the quality of end-of-life care. Quality 
measures provide not only information for oversight, but data with 
which to improve care practices and models. No core sets of end-of-life 
quality measures are required across provider settings. Even for 
certified hospices, reporting of quality measures has only recently 
been required, with each hospice deciding its own indicators. Hospice 
surveys are behind schedule and not conducted frequently enough.
  Facilitating greater advance planning and improving care at the end 
of life also requires an adequate workforce. Unfortunately, there is a 
substantial shortage of health professionals who specialize in 
palliative care. There is a severe shortage of physicians and advance 
practice nurses trained in palliative medicine. Contributing to these 
shortages is a shortage of medical and nursing school faculty in 
palliative medicine and care. There is also a lack of content about 
end-of-life care in medical school curricula. Medical students in 
general receive very little formal end-of-life education. Almost half 
of medical residents in a survey felt unprepared to address patients' 
fears of dying. For Americans to have a full range of choices in end-
of-life care, we must strengthen our health care workforce, including 
palliative care education of physicians and other health professionals.
  Care at the end-of-life can, and should, be better and more 
consistent with what Americans want. The Advance Planning and 
Compassionate Care Act takes enormous steps forward to fully inform 
consumers of their treatment options at the end of life and to actually 
address patient end-of-life care needs when the time comes. To promote 
advance care planning, this legislation provides both patients and 
their physicians with the information and tools to help them in this 
most personal and often difficult discussion.
  Last year's Medicare Improvements for Patients and Providers Act, PL 
110-275, took a significant step forward toward improving advance care 
planning. MIPPA included a provision that I authored, requiring 
physicians to provide an advance care planning consultation as part of 
the Welcome to Medicare physical exam. Unfortunately, less than 10 
percent of new enrollees use the Welcome to Medicare visit. The MIPPA 
provision also does not address the advance care planning needs of 
existing Medicare enrollees.
  The legislation we are introducing today establishes physician 
payment under Medicare, Medicaid, and CHIP for vital patient advance 
care planning conversations. It provides help in documenting decisions 
from these conversations in the form of advance directives and in the 
form of actionable orders for life sustaining treatment. It also takes 
steps to address the problem of accessing advance directives when 
needed, including state grants for electronic registries.
  This legislation establishes a National Geriatric and Palliative Care 
Service Corps, modeled after the National Health Service Corps, to 
increase the woefully inadequate supply

[[Page S5863]]

of geriatric and palliative specialists and to even out their 
geographic distribution. It adopts MedPAC's 2009 hospice payment 
reforms aimed at aligning payment with the actual trajectory of 
resources expended over hospice episodes of care, while remaining 
within the constraints of current reimbursement. Demonstration projects 
are funded to explore ways to better meet the needs of patients over 
longer time periods than the 6-month prognoses inherent in the hospice 
benefit.
  Certification standards and processes are developed for hospital-
based palliative care teams. Such teams are critical to providing 
consultation and care to dying patients. Quality measurement and 
oversight are strengthened, with development of end-of-life measures 
across care settings and greater data reporting requirements of 
hospices--so that we can make sure the hospice benefit is keeping pace 
with the changing diagnostic mix of patients that hospice serves.
  Finally, this bill takes the important step of establishing a 
National Center on Palliative and End-of-Life Care within the NIH. This 
is a vital step toward prioritizing biomedical research in the areas of 
palliative and end-of-life care. It will also serve as a symbol to 
remind us that, as in other phases of life, we need care at the end of 
life that addresses our individual needs and circumstances.
  Death is a serious, personal, and complicated issue that is 
eventually relevant to each and every one of us. Americans deserve end-
of-life care that is effective in fulfilling individual wishes, 
avoiding unnecessary disputes, and, most importantly, providing quality 
end-of-life care. Therefore, I urge my colleagues to join us in 
improving end-of-life care and reducing the amount of grief that 
inevitably comes with losing those who we hold dear.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                S. 1150

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

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Advance 
     Planning and Compassionate Care Act of 2009''.
       (b) Table of Contents.--The 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 raud and abuse.
Sec. 255. GAO study and report on provider adherence to advance 
              directives.

     SEC. 2. DEFINITIONS.

       In this Act:
       (1) Advance care planning.--The 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 directive.--The 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) CHIP.--The 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-care.--The 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 attorney.--The term ``health care 
     power of attorney'' means a legal document that identifies a 
     health care proxy or decisionmaker 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 will.--The 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) Medicaid.--The term ``Medicaid'' means the program 
     established under title XIX of the Social Security Act (42 
     U.S.C. 1396 et seq.).
       (8) Medicare.--The term ``Medicare'' means the program 
     established under title

[[Page S5864]]

     XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).
       (9) Orders for life-sustaining treatment.--The 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 care.--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.
       (11) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.

                     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.

       (a) In General.--Not 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) Establishment.--In 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.

     SEC. 102. ADVANCE CARE PLANNING INFORMATION CLEARINGHOUSES.

       (a) Expansion of National Clearinghouse for Long-Term Care 
     Information.--
       (1) Development.--Not later than January 1, 2010, the 
     Secretary shall develop an online clearinghouse to provide 
     comprehensive information regarding advance care planning.
       (2) Maintenance.--The 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) Content.--The 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); and
       (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) Development.--Not 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) Maintenance.--The 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) Content.--The pediatric advance care planning 
     clearinghouse shall provide advance care planning information 
     specific to children with life-threatening illnesses or 
     injuries and their families.

     SEC. 103. ADVANCE CARE PLANNING TOOLKIT.

       (a) Development.--Not 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) Maintenance.--The 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) Content.--The 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.

     SEC. 104. NATIONAL PUBLIC EDUCATION CAMPAIGN.

       (a) National Public Education Campaign.--
       (1) In general.--Not 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 campaign.--The 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 general.--Not 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 survey.--In order to evaluate the 
     effectiveness of the national campaign, the Secretary shall 
     conduct a baseline survey prior to implementation of the 
     campaign.
       (C) Reporting requirement.--Not 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) Repeal.--Section 4751(d) of the Omnibus Budget 
     Reconciliation Act of 1990 (42 U.S.C. 1396a note; Public Law 
     101-508) is repealed.

     SEC. 105. UPDATE OF MEDICARE AND SOCIAL SECURITY HANDBOOKS.

       (a) Medicare & You Handbook.--
       (1) In general.--Not later than 60 days after the date of 
     enactment of this Act, the Secretary shall update the online 
     version of

[[Page S5865]]

     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 versions.--The 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 Handbook.--The 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.

     SEC. 106. AUTHORIZATION OF APPROPRIATIONS.

       There 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).

                 Subpart B--State and Local Initiatives

     SEC. 111. FINANCIAL ASSISTANCE FOR ADVANCE CARE PLANNING.

       (a) Legal Assistance for Advance Care Planning.--
       (1) Definition of recipient.--Section 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 planning.--Section 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) Reports.--Section 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 appropriations.--Section 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 date.--This subsection and the amendments 
     made by this subsection take effect July 1, 2010.
       (b) State Health Insurance Assistance Programs.--
       (1) In general.--The 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 grants.--In 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; report.--As 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) Limitation.--No State shall be paid funds from a grant 
     made under this subsection prior to July 1, 2010.
       (3) Authorization of appropriations.--There 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 
     Planning.--Section 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 
     grants.--Payment 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 funds.--The 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 general.--The 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 funds.--Funds 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; report.--As 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.

[[Page S5866]]

       (C) Limitation.--No area agency on aging shall be paid 
     funds from a grant made under this subsection prior to July 
     1, 2010.
       (3) Authorization of appropriations.--There 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 Activities.--The 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.

     SEC. 112. GRANTS FOR PROGRAMS FOR ORDERS REGARDING LIFE 
                   SUSTAINING TREATMENT.

       (a) In General.--The 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 Activities.--Activities 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 Funds.--In 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) Definitions.--In 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 Appropriations.--To 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.

                      PART II--PROVIDER EDUCATION

     SEC. 121. PUBLIC PROVIDER ADVANCE CARE PLANNING WEBSITE.

       (a) Development.--Not 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) Maintenance.--The website, shall be maintained and 
     publicized by the Secretary on an ongoing basis.
       (c) Content.--The 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.

     SEC. 122. CONTINUING EDUCATION FOR PHYSICIANS AND NURSES.

       (a) In General.--Not 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 general.--The 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 physicians.--The 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.

   Subtitle B--Portability of Advance Directives; Health Information 
                               Technology

     SEC. 131. PORTABILITY OF ADVANCE DIRECTIVES.

       (a) Medicare.--Section 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) Medicaid.--Section 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

[[Page S5867]]

       (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) CHIP.--Section 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) Study.--The Secretary shall conduct a study regarding 
     the implementation of the amendments made by subsections (a) 
     and (b).
       (2) Report.--Not 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 general.--Subject 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 amendment.--
     In 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.

     SEC. 132. STATE ADVANCE DIRECTIVE REGISTRIES; DRIVER'S 
                   LICENSE ADVANCE DIRECTIVE NOTATION.

       Part 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:

     ``SEC. 399U. STATE ADVANCE DIRECTIVE REGISTRIES.

       ``(a) State Advance Directive Registry.--In 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 Program.--Beginning 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 general.--To 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 mechanism.--The 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 Report.--For 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) Authorization.--There is authorized to be 
     appropriated to carry out this section $20,000,000 for fiscal 
     year 2010 and each fiscal year thereafter.

     ``SEC. 399V. DRIVER'S LICENSE ADVANCE DIRECTIVE NOTATION.

       ``(a) In General.--Beginning 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) Eligibility.--To 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 Report.--For 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) Authorization.--There is authorized to be 
     appropriated to carry out this section $50,000,000 for fiscal 
     year 2010 and each fiscal year thereafter.''.

     SEC. 133. GAO STUDY AND REPORT ON ESTABLISHMENT OF NATIONAL 
                   ADVANCE DIRECTIVE REGISTRY.

       (a) Study.--The 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) Report.--Not 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.

      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.

       (a) Study.--
       (1) In general.--The 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 studied.--The 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 1 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;

[[Page S5868]]

       (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 care.--For 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 Congress.--Not 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) Consultation.--In conducting the study and developing 
     the report under this section, the Secretary shall consult 
     with the Uniform Law Commissioners, and other interested 
     parties.

                      TITLE II--COMPASSIONATE CARE

                   Subtitle A--Workforce Development

                     PART I--EDUCATION AND TRAINING

     SEC. 201. NATIONAL GERIATRIC AND PALLIATIVE CARE SERVICES 
                   CORPS.

       Section 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) Establishment.--Not 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) Duties.--The Corps shall be utilized by the Secretary 
     to provide geriatric and palliative care services within 
     health professional shortage areas.
       ``(3) Application of provisions.--The 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) Report.--Not 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).''.

     SEC. 202. EXEMPTION OF PALLIATIVE MEDICINE FELLOWSHIP 
                   TRAINING FROM MEDICARE GRADUATE MEDICAL 
                   EDUCATION CAPS.

       (a) Direct Graduate Medical Education.--Section 
     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 
     training.--For 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 Education.--Section 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.''.

     SEC. 203. MEDICAL SCHOOL CURRICULA.

       (a) In General.--The 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) Training.--Under 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) Distribution.--Not later than January 1, 2011, the 
     Secretary shall disseminate the guidelines established under 
     subsection (a) to medical schools.
       (d) Compliance.--Effective 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.

        Subtitle B--Coverage Under Medicare, Medicaid, and CHIP

               PART I--COVERAGE OF ADVANCE CARE PLANNING

     SEC. 211. MEDICARE, MEDICAID, AND CHIP COVERAGE.

       (a) Medicare.--
       (1) In general.--Section 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:

                  ``Advance Care Planning Consultation

       ``(hhh)(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 decisionmaker (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,

[[Page S5869]]

     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) Payment.--Section 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 limitation.--Section 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 date.--The amendments made by this subsection 
     shall apply to consultations furnished on or after January 1, 
     2011.
       (b) Medicaid.--
       (1) Mandatory benefit.--Section 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 assistance.--Section 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 decisionmaker (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 assistance.--Section 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 general.--Section 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 care.--The 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 amendment.--Section 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) Medicare.--Section 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 chip.--Section 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 Date.--The amendments made by this section 
     take effect January 1, 2010.

                            PART II--HOSPICE

     SEC. 221. ADOPTION OF MEDPAC HOSPICE PAYMENT METHODOLOGY 
                   RECOMMENDATIONS.

       Section 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

[[Page S5870]]

     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.''.

     SEC. 222. REMOVING HOSPICE INPATIENT DAYS IN SETTING PER DIEM 
                   RATES FOR CRITICAL ACCESS HOSPITALS.

       Section 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.''.

     SEC. 223. HOSPICE PAYMENTS FOR DUAL ELIGIBLE INDIVIDUALS 
                   RESIDING IN LONG-TERM CARE FACILITIES.

       (a) In General.--Section 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 Facilities.--For 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 general.--Section 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 general.--Except 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 amendment.--
     In the case of a State plan under title XIX of the Social 
     Security Act (42 U.S.C. 1396 et seq.) which the Secretary 
     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.

     SEC. 224. DELINEATION OF RESPECTIVE CARE RESPONSIBILITIES OF 
                   HOSPICE PROGRAMS AND LONG-TERM CARE FACILITIES.

       Section 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 Facilities.--Not 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.''.

     SEC. 225. ADOPTION OF MEDPAC HOSPICE PROGRAM ELIGIBILITY 
                   CERTIFICATION AND RECERTIFICATION 
                   RECOMMENDATIONS.

       In 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''.

     SEC. 226. CONCURRENT CARE FOR CHILDREN.

       (a) Permitting Medicare Hospice Beneficiaries 18 Years of 
     Age or Younger to Receive Curative Care.--
       (1) In general.--Section 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 amendment.--Section 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) Medicaid.--Section 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) CHIP.--Section 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 Date.--The amendments made by this section 
     shall apply to items and services furnished on or after 
     January 1, 2011.

     SEC. 227. MAKING HOSPICE A REQUIRED BENEFIT UNDER MEDICAID 
                   AND CHIP.

       (a) Mandatory Benefit.--
       (1) Medicaid.--
       (A) In general.--Section 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 amendment.--Section 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) CHIP.--Section 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 Date.--The amendments made subsection (a) 
     take effect on January 1, 2011.

     SEC. 228. MEDICARE HOSPICE PAYMENT MODEL DEMONSTRATION 
                   PROJECTS.

       (a) Establishment.--Not 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.

[[Page S5871]]

       (b) Waiver Authority.--The 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) Reports.--The Secretary shall submit to Congress 
     periodic reports on the demonstration projects conducted 
     under this section.

     SEC. 229. MEDPAC STUDIES AND REPORTS.

       (a) Study and Report Regarding an Alternative Payment 
     Methodology for Hospice Care Under the Medicare Program.--
       (1) Study.--The 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) Report.--Not 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) Study.--The Commission shall conduct a study on rural 
     Medicare hospice transportation mileage to determine 
     potential Medicare reimbursement changes to account for 
     potential higher costs.
       (2) Report.--Not 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) Study.--The 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) Report.--Not 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.

     SEC. 230. HHS EVALUATIONS.

       (a) Evaluation of Access to Hospice and Hospital-Based 
     Palliative Care.--
       (1) Evaluation.--The 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) Report.--Not 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) Evaluation.--The Secretary, acting through the Director 
     of the Centers for Medicare and Medicaid Services, shall 
     evaluate the awareness and use of hospice respite care by 
     informal caregivers of beneficiaries under Medicare, 
     Medicaid, and CHIP.
       (2) Report.--Not 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.

                    Subtitle C--Quality Improvement

     SEC. 241. PATIENT SATISFACTION SURVEYS.

       Not 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.

     SEC. 242. DEVELOPMENT OF CORE END-OF-LIFE CARE QUALITY 
                   MEASURES ACROSS EACH RELEVANT PROVIDER SETTING.

       (a) In General.--The 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) Requirements.--For 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.

     SEC. 243. ACCREDITATION OF HOSPITAL-BASED PALLIATIVE CARE 
                   PROGRAMS.

       (a) In General.--The 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) Reporting.--Not 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) Accreditation.--Not 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) Definitions.--For 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.

     SEC. 244. SURVEY AND DATA REQUIREMENTS FOR ALL MEDICARE 
                   PARTICIPATING HOSPICE PROGRAMS.

       (a) Hospice Surveys.--Section 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 Data.--Section 
     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

[[Page S5872]]

     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.''.

       Subtitle D--Additional Reports, Research, and Evaluations

     SEC. 251. NATIONAL CENTER ON PALLIATIVE AND END-OF-LIFE CARE.

       Part 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:

    ``Subpart 7--National Center on Palliative and End-of-Life Care

     ``SEC. 485J. NATIONAL CENTER ON PALLIATIVE AND END-OF-LIFE 
                   CARE.

       ``(a) Establishment.--Not 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) Purpose.--The general purpose of the Center is to 
     conduct and support research relating to palliative and end-
     of-life care interventions and approaches.
       ``(c) Activities.--The 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.''.

     SEC. 252. NATIONAL MORTALITY FOLLOWBACK SURVEY.

       (a) In General.--Not 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) Purpose.--The 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 general.--In 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 questions.--Additional 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.

     SEC. 253. DEMONSTRATION PROJECTS FOR USE OF TELEMEDICINE 
                   SERVICES IN ADVANCE CARE PLANNING.

       (a) In General.--Not 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) Duration.--The demonstration project under this section 
     shall be conducted for at least a 3-year period.
       (c) Definitions.--For 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) Funding.--There are authorized to be appropriated to 
     the Secretary such sums as may be necessary to carry out this 
     section.

     SEC. 254. INSPECTOR GENERAL INVESTIGATION OF FRAUD AND ABUSE.

       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''), 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.

     SEC. 255. GAO STUDY AND REPORT ON PROVIDER ADHERENCE TO 
                   ADVANCE DIRECTIVES.

       Not 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.
                                 ______