,,ii #aacth ,,congress #ast ,session ,s4 #adci ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,august #a1 #bjac ,mr4 ,warner 7for himself and ,mr4 ,isakson7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to provide for advanced illness care coordination services for ,medicare beneficiaries1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,care ,planning ,act of #bjac4 7b7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4 ,sec4 #b4 ,findings4 ,sec4 #c4 ,improvement of advanced illness planning and coordination4 ,sec4 #d4 ,quality measurement development4 ,sec4 #e4 ,inclusion of advance care planning materials in the ,medicare ,you handbook4 ,sec4 #f4 ,care ,planning ,advisory ,board4 ,sec4 #g4 ,improvement of policies related to the use and portability of advance directives4 ,sec4 #h4 ,additional requirements for facilities4 ,sec4 #i4 ,grants for increasing public awareness of advance care planning and advanced illness care4 ,sec4 #aj4 ,,hhs study and report on the storage of advance directives4 ,sec4 #aa4 ,,gao study and report on the provisions of1 and amendments made by1 this ,act4 ,sec4 #ab4 ,consultation with the ,care ,planning ,advisory ,board4 ,sec4 #ac4 ,rule of construction4 #b4 ,findings ,congress makes the following findings3 7#a7 ,the population of the ,united ,states is estimated to age rapidly1 with the number of people over the age of #fe set to double to more than #gb1jjj1jjj1 or #a in #e ,americans1 over the next two decades4 7#b7 ,americans today are living longer and healthier lives than ever before in the history of the ,united ,states yet are also facing increased incidence of multiple serious conditions as aging progresses4 7#c7 ,americans with advanced illness face a complicated and fragmented system of care delivery that puts them at risk for repeat hospitalizations1 adverse drug reactions1 and conflicting medical advice that may be overwhelming to individuals and families4 7#d7 ,the progression of advanced illness leads to the need for increasingly intensive decision support1 health care services1 and support from family caregivers4 7#e7 ,the complexity of care needed by individuals with advanced illness may result in uncoordinated care1 adverse health outcomes1 frustration1 wasted time1 and undue emotional burdens on individuals and their family caregivers4 7#f7 ,numerous private sector leaders1 including hospitals1 health systems1 home health agencies1 hospice programs1 long-term care providers1 employers1 and other entities1 have put in place innovative solutions to provide more comprehensive and coordinated care for ,americans living with advanced illness4 7#g7 ,hospice programs1 as one of the longest standing ,medicare care coordination benefits that offer a comprehensive set of services via an interdisciplinary team working to provide person- and family-centered care to the frailest and most vulnerable individuals in our communities1 can serve as a model for advanced illness care delivery4 7#h7 ,palliative care programs that serve patients beginning at diagnosis with advanced illness and provide care designed to reduce the symptom burden of illness can serve as a model for interdisciplinary team care planning based on the individual's goals of care4 7#i7 ,the ,government of the ,united ,states1 as the ,nation's largest purchaser of health care services1 must learn from these innovators and encourage health care providers to furnish more supportive and comprehensive advanced illness care to improve the efficacy and quality of health care delivered for generations of ,americans to come4 7#aj7 ,health care providers who serve individuals with advanced illness face complicated care systems and legal concerns that may result in over- or under-treatment of individuals with advanced illness4 7#aa7 ,individuals have the well-established right to accept or reject medical treatment that is offered1 as well as the well-established right to document their preferences for how treatment decisions should be made if1 at some point in the future1 they lose the ability to make health care decisions4 7#ab7 ,too often1 individuals with advanced illness do not understand the conditions they are facing or their treatment options1 and they do not receive the information or support they need to evaluate treatment options in light of their personal goals and values and to document treatment plans in a manner that allows providers and facilities to follow their plans4 7#ac7 ,providing quality services and planning support to individuals with advanced illness will protect and preserve their dignity4 #c4 ,improvement of advanced illness planning and coordination 7a7 ,medicare coverage of planning services 7#a7 ,coverage ,section #ahfa7s77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7s77#b77 is amended-- 7,a7 in subparagraph 7,,ee71 by striking and at the end2 7,b7 in subparagraph 7,,ff71 by inserting and at the end2 and 7,c7 by inserting after subparagraph 7,,ff7 the following new paragraph3 7,,gg7 planning services 7as defined in subsection 7iii772 4 7#b7 ,services described ,section #ahfa of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7 is amended by adding at the end the following new subsection3 7iii7 ,planning services 7#a7 7,a7 ,the term planning services means a voluntary decisionmaking process that includes the elements described in paragraph 7#b7 and is furnished to a planning services eligible individual by an applicable provider through an interdisciplinary team4 7,b7 ,planning services may only be furnished to a planning services eligible individual under this title once in each #ab-month period4 7#b7 7,a7 ,the elements described in this paragraph are the following3 7i7 ,one or more face-to-face encounters between one or more members of the interdisciplinary team and the individual and1 at the individual's discretion1 family caregivers1 or1 for an individual who lacks decisionmaking capacity under ,state law1 the individual's legally authorized representative4 7ii7 ,the provision of information about the typical trajectory of illnesses or conditions that affect the individual1 including foreseeable care decisions that may need to be made at a future time when the individual is likely to be unable to make decisions due to temporary or permanent cognitive incapacity4 7iii7 ,assisting the individual in defining and articulating goals of care1 values1 and preferences4 7iv7 ,providing the individual with 7and discussing7 information about the benefits and burdens of a relevant range of treatment options available to the individual1 including disease modifying or potentially curative treatment1 palliative care1 which may be provided alone or in conjunction with disease modifying treatment1 and1 when the individual may be currently eligible or may become eligible for hospice care due to disease progression1 hospice care4 ,an applicable provider shall present and discuss relevant treatment options that may help the individual to achieve goals of care and may not exclude options based on an individual's age1 disability status1 or the presence of advanced illness unless1 in the provider's clinical judgment1 a treatment option will not achieve the outcome sought by the individual4 7v7 ,assisting the individual in evaluating treatment options and approaches to care to identify those that most closely align with the individual's goals of care1 values1 and preferences4 7vi7 ,preparing1 and sharing with relevant providers1 documentation-- 7,i7 that states the individual's goals of care1 preferences1 and values1 preferred decisionmaking strategies1 and a plan of care that is concrete1 achievable1 and actionable2 and 7,,ii7 that is in a paper or electronic format1 on ,state or locally recognized forms that are used for the purpose of assuring that providers can follow the plan across care settings1 such as advance directives or portable treatment orders4 7vii7 ,referrals to providers1 including medical and social service providers1 who deliver care consistent with the plan4 7viii7 ,providing culturally and educationally appropriate training for the individual and family caregivers to support their ability to carry out the plan4 7,b7 ,even when the individual's decisional capacity is impaired and another person or entity1 such as an appointed agent1 proxy1 or surrogate1 is exercising legal authority under ,state law governing decisionmaking on behalf of incapacitated individuals1 the interdisciplinary team shall make a reasonable attempt to include the individual in the planning process4 7#c7 ,for purposes of this subsection1 the term planning services eligible individual means an individual that meets at least one of the following criteria3 7,a7 ,the individual is diagnosed with metastatic or locally advanced cancer4 7,b7 ,the individual is diagnosed with ,alzheimer's disease or another progressive dementia4 7,c7 ,the individual is diagnosed with late-stage neuromuscular disease4 7,d7 ,the individual is diagnosed with late-stage diabetes4 7,e7 ,the individual is diagnosed with late-stage kidney1 liver1 heart1 gastrointestinal1 cerebrovascular1 or lung disease4 7,f7 ,the individual needs assistance with two or more activities of daily living 7defined as bathing1 dressing1 eating1 getting out of bed or a chair1 mobility1 and toileting7 that are caused by one or more progressive illnesses4 7,g7 ,the individual meets other criteria determined appropriate by the ,secretary1 including criteria that are designed to identify individuals with a need for planning services due to advancing illness or risk of decline in cognitive function over time4 7#d7 ,for purposes of this subsection1 the term applicable provider means a hospice program 7as defined in section #ahfa7;dd77#b77 or other provider of services 7as defined in section #ahfa7u77 or supplier 7as defined in section #ahfa7;d77 that-- 7,a7 furnishes planning services through an interdisciplinary team2 and 7,b7 meets such other requirements the ,secretary may determine to be appropriate4 7#e7 7,a7 ,for purposes of this subsection1 the term interdisciplinary team means a group that-- 7i7 includes-- 7,i7 a core team of a physician or an advance practice registered nurse1 a social worker1 a nurse2 and1 subject to subparagraph 7,b71 a chaplain1 a minister1 or the individual's personal religious or spiritual advisor2 and 7,,ii7 when necessary to meet an individual's planning needs1 other professionals1 which may include a pharmacist1 a licensed clinical social worker1 and a psychologist1 either as ongoing team members or who may be brought in as needed to address the individual's planning needs2 and 7ii7 meets requirements that may be established by the ,secretary4 7,b7 ,an applicable provider furnishing planning services to a planning services eligible individual shall offer to the individual 7or the individual's legally authorized representative when the individual has been found to lack decisional capacity7 the opportunity to select either a chaplain affiliated with the provider1 a minister1 or personal religious or spiritual advisor who can help to represent the individual's goals1 values1 and preferences to serve as a core team member at the individual's 7or legally authorized representative's7 request4 7,c7 ,the requirements established by the ,secretary under subparagraph 7,a77ii7 shall include a requirement that interdisciplinary team members 7except for the individuals's chosen minister or personal religious or spiritual advisor7 have training and experience in delivering person-directed planning services and in team-based delivery of services for individuals with dementing illness and individuals with advanced illness4 4 7#c7 ,payment under physician fee schedule ,section #ahdh7;j77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#d7;j77#c77 is amended by inserting 7#b77;,,gg71 after 7#b77;,,ff7 7including administration of the health risk assessment714 7#d7 ,frequency limitation ,section #ahfb7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciey7a77 is amended-- 7,a7 in paragraph 7#a7-- 7i7 in subparagraph 7,o71 by striking and at the end2 7ii7 in subparagraph 7,p7 by striking the semicolon at the end and inserting 1 and2 and 7iii7 by adding at the end the following new subparagraph3 7,q7 in the case of planning services 7as defined in section #ahfa7;iii77#a771 which are furnished more frequently than is covered under subparagraph 7,b7 of such section2 2 and 7,b7 in paragraph 7#g71 by striking or 7,p7 and inserting 7,p71 or 7,q74 7#e7 ,effective date ,the amendments made by this subsection shall apply to services furnished on or after ,january #a1 #bjae4 7b7 ,medicaid coverage of planning services 7#a7 ,in general ,section #aije7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7a77 is amended-- 7,a7 by redesignating paragraph 7#bi7 as paragraph 7#cj72 7,b7 in paragraph 7#bh71 by striking at the end and2 and 7,c7 by inserting after paragraph 7#bh7 the following new paragraph3 7#bi7 planning services 7as defined in section #ahfa7;iii772 and 4 7#b7 ,conforming amendment ,section #aijb7;a77#aj77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77#aj77;,a77 is amended by striking and 7#bh7 and inserting 1 7#bh71 and 7#bi74 7#c7 ,effective date 7,a7 ,in general ,except as provided in subparagraph 7,b71 the amendments made by paragraphs 7#a7 and 7#b7 take effect on ,january #a1 #bjae4 7,b7 ,extension of effective date for ,state law amendment ,in the case of a ,state plan under title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 which the ,secretary determines requires ,state legislation in order for the plan to meet the additional requirements imposed by the amendments made by paragraphs 7#a7 and 7#b71 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 the enactment of this ,act4 ,for purposes of the previous sentence1 in the case of a ,state that has a #b-year legislative session1 each year of the session is considered to be a separate regular session of the ,state legislature4 7c7 ,advanced illness care coordination services project ,section #aaae;,a7b77#b7 of title ,,xi of the ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7b77#b77 is amended-- 7#a7 in subparagraph 7,a71 by adding at the end the following new sentence3 ,the models selected under this subparagraph shall include the model described in subparagraph 7,d7 and such model shall be implemented by not later than ,december #ca1 #bjae42 and 7#b7 by adding at the end the following new subparagraph3 7,d7 ,advanced illness care coordination services model 7i7 ,model 7,i7 ,in general ,the model described in this subparagraph is a model under which payments are made to applicable providers that furnish advanced illness care coordination services to eligible individuals4 7,,ii7 ,requirement ,at least one applicable provider selected for participation under the model shall be a hospice program 7as defined in section #ahfa7;dd77#b774 7ii7 ,applicable provider ,in this subparagraph1 the term applicable provider means a hospice program 7as defined in section #ahfa7;dd77#b77 or other provider of services 7as defined in section #ahfa7u77 or supplier 7as defined in section #ahfa7;d77 that-- 7,i7 furnishes advanced illness care coordination services through an interdisciplinary team 7as defined in section #ahfa7;iii77#e772 and 7,,ii7 meets such other requirements the ,secretary may determine to be appropriate4 7iii7 ,advanced illness care coordination services ,in this subparagraph1 the term advanced illness care coordination services means the following services3 7,i7 ,planning services 7as defined in section #ahfa7;iii774 7,,ii7 ,a multi-dimensional assessment of the individual's strengths and limitations4 7,,iii7 ,an assessment of the individual's formal and informal supports1 including family caregivers4 7,,iv7 ,comprehensive medication review and management 7including1 if appropriate1 counseling and self-management support74 7,v7 ,in-home supportive services for the eligible individual and family caregivers consistent with the care plan4 7,,vi7 #bd-;hour access to emergency support in person or via telephone or telemedicine with the individual's medical record and care plan available to the responder4 7,,vii7 ,coordination across health care and social service systems1 including involvement of the interdisciplinary team to evaluate quality and address concerns4 7,,viii7 ,such other services as specified by the ,secretary4 7iv7 ,eligible individual ,in this subparagraph1 the term eligible individual means an individual who-- 7,i7 is entitled to1 or enrolled for1 benefits under part ,a of title ,,xviii and enrolled under part ,b of such title1 but not enrolled under part ,c of such title2 and 7,,ii7 has the need for assistance with two or more activities of daily living 7defined as bathing1 dressing1 eating1 getting out of bed or a chair1 mobility1 and toileting7 that are caused by one or more progressive conditions4 4 #d4 ,quality measurement development 7a7 ,in general ,section #ica7;c77#b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bii;b-#ca7;c77#b77 is amended-- 7#a7 by redesignating subparagraphs 7,i7 and 7,j7 as subparagraphs 7,l7 and 7,m71 respectively2 and 7#b7 by inserting after subparagraph 7,h7 the following new subparagraphs3 7,i7 the process of eliciting and documenting patient 7and1 where relevant and appropriate1 family caregiver7 goals1 preferences1 and values from the patient or from a legally authorized representative1 including the articulation of goals that accurately reflect how the patient wants to live2 7,j7 the effectiveness1 patient-centeredness 7and1 where relevant1 family caregiver-centeredness71 and accuracy of care plans1 including documentation of individual goals1 preferences1 and values2 7,k7 agreement and consistency among-- 7i7 the patient's goals1 values1 and preferences2 7ii7 any documented care plan2 7iii7 the treatment delivered2 and 7iv7 outcomes of treatment2 4 7b7 ,authorization of appropriations ,there are authorized to be appropriated to the ,secretary of ,health and ,human ,services to carry out the amendments made by this section1 #e1jjj1jjj for fiscal year #bjad4 ,amounts appropriated under the preceding sentence shall remain available until expended4 #e4 ,inclusion of advance care planning materials in the ,medicare ,you handbook 7a7 ,in general ,section #ahjd7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;b-#b7;a77 is amended-- 7#a7 in paragraph 7#b71 by striking and at the end2 7#b7 in paragraph 7#c71 by striking the period at the end and inserting a semicolon2 and 7#c7 by inserting after paragraph 7#c7 the following new paragraphs3 7#d7 information on-- 7,a7 care planning2 7,b7 how individual goals1 values1 and preferences should be considered in framing a care plan2 and 7,c7 a range of approaches for treating advanced illness1 including disease modifying options1 palliative care that supports individuals from the onset of advanced illness and can be provided at the same time as all other care types1 and hospice care2 and 7#e7 information on documentation options for care planning or advance care planning1 including advance directives and portable treatment orders4 4 7b7 ,effective date ,the amendments made by this section shall apply to notices distributed on or after ,january #a1 #bjae4 #f4 ,care ,planning ,advisory ,board 7a7 ,establishment ,the ,secretary of ,health and ,human ,services shall establish the ,care ,planning ,advisory ,board 7in this section referred to as the ,advisory ,board74 7b7 ,membership 7#a7 ,in general ,the ,advisory ,board shall be composed of #ae members1 to be appointed not later than #cj days after the date of the enactment of this ,act1 as follows3 7,a7 ,the ,president of the ,united ,states shall appoint #c members4 7,b7 ,the majority leader of the ,senate shall appoint #c members4 7,c7 ,the minority leader of the ,senate shall appoint #c members4 7,d7 ,the ,speaker of the ,house of ,representatives shall appoint #c members4 7,e7 ,the minority leader of the ,house of ,representatives shall appoint #c members4 7#b7 ,representation ,the membership of the ,advisory ,board shall include individuals who 7with a preference for individuals who also are members of the group they are appointed to represent7-- 7,a7 represent the interests of-- 7i7 patient advocacy groups2 7ii7 older adults2 7iii7 individuals with cognitive or functional limitations2 7iv7 family caregivers for individuals described in clause 7ii7 or 7iii72 7v7 palliative care and hospice providers2 7vi7 researchers2 7vii7 ethicists2 7viii7 faith communities2 7ix7 health care providers2 and 7x7 health care facilities2 7,b7 have demonstrated experience in dealing with issues related to health care decisionmaking and health care policy2 and 7,c7 represent the health care interests and needs of a variety of geographic areas and demographic groups4 7c7 ,duties ,the ,advisory ,board shall advise the ,secretary on issues related to care planning1 advanced illness coordination services1 advance care planning1 and documentation options1 including how to-- 7#a7 assure that individuals with advanced illness receive person- and family-centered care2 7#b7 assist individuals with advanced illness to develop a treatment plan that is formed around their goals1 values1 and preferences1 that is informed by research on disease trajectory1 and that includes a documented plan that is realistic1 actionable1 and concrete1 and that may include the use of advance directives1 portable treatment orders 7where appropriate71 or other forms used in the ,state or locality2 7#c7 develop and monitor a demonstration program that includes an optimal service array to support individuals with advanced illness with services designed to manage symptoms as illness progresses2 7#d7 provide health care that is consistent with individuals' current treatment preferences or1 for those whose capacity to make decisions is impaired1 with the individuals' values and goals1 and specific directions documented in advance directives and portable treatment orders2 7#e7 encourage provider participation in educational and training activities addressing care planning1 advanced illness care1 and advance care planning2 7#f7 develop quality measures1 including process1 outcome1 and experience measures1 that applicable providers should report for planning services 7as defined in section #ahfa7;iii7 of the ,social ,security ,act1 as added by section #c72 7#g7 determine the appropriate role for discharge planners in educating individuals and their families about care planning services1 advance care planning1 palliative care1 hospice1 advance directives1 portable treatment orders1 and other relevant services1 supports1 planning tools1 and documentation options2 7#h7 develop and promote best practices in communications about advanced illness between providers1 individuals1 and family caregivers in different settings1 including acute care hospitals2 7#i7 evaluate the feasibility of replacing life expectancy in months with clinical criteria to determine eligibility for hospice care2 and 7#aj7 promote effective advance care planning and effective and appropriate use of portable treatment orders4 7d7 ,application of ,,faca ,the ,federal ,advisory ,committee ,act 7#e ,u4,s4,c4 ,app47 shall apply to the ,advisory ,board4 7e7 ,pay and reimbursement 7#a7 ,no compensation for members of ,advisory ,board ,except as provided in paragraph 7#b71 a member of the ,advisory ,board may not receive pay1 allowances1 or benefits by reason of their service on the ,board4 7#b7 ,travel expenses ,each member shall receive travel expenses1 including per diem in lieu of subsistence under subchapter ,i of chapter #eg of title #e1 ,united ,states ,code4 7f7 ,report ,not later than #c years after the establishment of the ,advisory ,board1 the ,advisory ,board shall submit to ,congress a final report containing the findings and conclusions of the ,advisory ,board1 together with recommendations for such legislation and administrative actions as the ,advisory ,board considers appropriate4 7g7 ,termination ,the ,advisory ,board shall terminate #cj days after submitting the report under subsection 7f74 7h7 ,authorization of appropriations ,there are authorized to be appropriated such sums as may be necessary to carry out this section4 #g4 ,improvement of policies related to the use and portability of advance directives 7a7 ,medicare ,section #ahff7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7f77 is amended-- 7#a7 in paragraph 7#a7-- 7,a7 in subparagraph 7,a77i71 by striking ,state law and all that follows through medical care and inserting relevant ,state and ,federal law 7whether statutory or as recognized by the courts7 to make decisions concerning medical care2 7,b7 by striking subparagraph 7,b72 7,c7 by redesignating subparagraphs 7,c71 7,d71 and 7,e7 as subparagraphs 7,g71 7,h71 and 7,i71 respectively2 7,d7 by inserting after subparagraph 7,a7 the following new subparagraphs3 7,b7 to document in a prominent part of the individual's current medical record whether or not the individual has an advance directive or portable treatment order1 to request a copy of the advance directive or portable treatment order1 as applicable1 and if received1 to include the copy 7or the content of the document or documents7 in a prominent part of such record2 7,c7 to provide each individual with the opportunity to discuss the information provided pursuant to subparagraph 7,a7 with an appropriately trained employee or volunteer of the provider or organization2 7,d7 for an individual with decisional capacity under ,state law1 to follow the individual's current treatment instructions1 as expressed in writing or through verbal or nonverbal communications2 7,e7 for an individual who lacks decisional capacity-- 7i7 to ensure that treatment decisions are made in accordance with current preferences1 values1 and goals of the individual1 when possible to ascertain and follow1 and in accordance with current advance directives and portable treatment orders that are valid under ,state law where the care is delivered1 and instructions provided by legally authorized representatives in accordance with ,state and ,federal law2 7ii7 in the absence of a current advance directive or portable treatment order that is valid under ,state law where the care is delivered1 to deliver treatment based on credible evidence of the individual's treatment preferences1 goals1 and values1 such as a current advance directive or portable treatment order executed in another ,state or past statements about treatment preferences2 and 7iii7 to reconcile actual or suspected discrepancies among advance directives1 portable treatment orders1 and other evidence in accordance with ,state law1 and1 where ,state law is silent1 to reconcile discrepancies in the manner most likely to deliver treatment that is consistent with the individual's treatment preferences1 goals1 and values2 7,f7 that specify narrow1 but potentially recurring1 conditions or circumstances under which an advance directive1 portable treatment order1 or treatment directions from an individual or legally authorized representative would not be followed1 such as-- 7i7 where the validity or authenticity of a document is in question2 7ii7 where there is evidence that an individual's preferences changed after the individual documented preferences in an advance directive or portable treatment order2 7iii7 where the treatment sought by the individual is not medically indicated2 and 7iv7 because of conscience objections in accordance with paragraph 7#c72 2 7,e7 in subparagraph 7,h71 as redesignated by subparagraph 7,c71 by striking ,state law and all that follows through respecting and inserting this section and relevant ,state and ,federal law 7whether statutory or as recognized by the courts7 respecting2 7,f7 in subparagraph 7,i71 as redesignated by subparagraph 7,c71 by inserting and portable treatment orders before the period at the end2 7,g7 in the flush matter at the end1 by striking 7,c7 and inserting 7,g72 and 7,h7 by adding at the end the following new sentence3 ,nothing in subparagraph 7,d7 or 7,e7 shall be construed to apply to sterilization or abortion42 7#b7 by redesignating paragraphs 7#c7 and 7#d7 as paragraphs 7#d7 and 7#e71 respectively2 7#c7 by inserting after paragraph 7#b7 the following new paragraph3 7#c7 ,nothing in this section shall be construed to prohibit the application of a ,state law which allows for an objection on the basis of conscience for any health care provider or any agent of such provider which as a matter of conscience cannot implement an advance directive4 2 7#d7 in paragraph 7#d71 as redesignated by paragraph 7#b7-- 7,a7 by striking written2 7,b7 by striking ,state law and inserting ,state or ,federal law2 and 7,c7 by striking of the ,state2 7#e7 by redesignating paragraph 7#e71 as redesignated by paragraph 7#b71 as paragraph 7#f72 7#f7 by inserting after paragraph 7#d7 the following new paragraph3 7#e7 ,in this subsection1 the term portable treatment order means a treatment order designed to document a clinical process that includes shared1 informed medical decisionmaking1 that reflects the individual's goals of care and values1 and that is designed to apply across care settings1 including the home4 2 and 7#g7 by inserting after paragraph 7#f71 as redesignated by paragraph 7#f71 the following new paragraph3 7#g7 ,nothing in this subsection shall permit the ,secretary to seek civil penalties1 including exclusion from participation in the program under this title or the program under title ,,xix1 against an individual or entity if the individual or entity-- 7,a7 used reasonable efforts to deliver care that is consistent with an individual's goals1 preferences1 and values when addressing decisionmaking for an individual who lacks decisional capacity2 or 7,b7 declined to furnish care in accordance with paragraph 7#c74 4 7b7 ,medicaid ,section #aijb7w7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7w77 is amended-- 7#a7 in paragraph 7#a7-- 7,a7 in subparagraph 7,a77i71 by striking ,state law and all that follows through medical care and inserting relevant ,state and ,federal law 7whether statutory or as recognized by the courts7 to make decisions concerning medical care2 7,b7 by striking subparagraph 7,b72 7,c7 by redesignating subparagraphs 7,c71 7,d71 and 7,e7 as subparagraphs 7,f71 7,g71 and 7,h71 respectively2 7,d7 by inserting after subparagraph 7,a7 the following new subparagraphs3 7,b7 to document in a prominent part of the individual's current medical record whether or not the individual has an advance directive or portable treatment order1 to request a copy of the advance directive and or portable treatment order1 and if received1 to include the copy 7or the content of the document or documents7 in a prominent part of such record2 7,c7 to provide each individual with the opportunity to discuss the information provided pursuant to subparagraph 7,a7 with an appropriately trained personnel of the provider or organization2 7,d7 for an individual with decisional capacity under ,state law1 to follow the individual's current treatment instructions1 as expressed in writing or through verbal or non-verbal communications2 7,e7 for an individual who lacks decisional capacity-- 7i7 to ensure that treatment decisions are made in accordance with ,state law addressing legally authorized representatives and advance directives2 7ii7 in the absence of a current advance directive or portable treatment order1 to deliver treatment based on credible evidence of the individual's treatment preferences1 goals1 and values1 such as an advance directive or portable treatment order executed in another ,state or past statements about treatment preferences2 and 7iii7 to reconcile actual or suspected discrepancies among advance directives1 portable treatment orders1 and other evidence in accordance with ,state law1 and1 where ,state law is silent1 to reconcile discrepancies in the manner most likely to deliver treatment that is consistent with the individual's treatment preferences1 goals1 and values2 7,f7 that specify narrow1 but potentially recurring1 conditions or circumstances under which an advance directive1 portable treatment order1 or treatment directions from an individual or legally authorized representative would not be followed1 such as-- 7i7 where the validity or authenticity of a document is in question2 7ii7 where there is evidence that an individual's preferences changed after the individual documented preferences in an advance directive or portable treatment order2 7iii7 where the treatment sought by the individual is not medically indicated2 and 7iv7 because of conscience objections in accordance with paragraph 7#c72 2 7,e7 in subparagraph 7,h71 as redesignated by subparagraph 7,c71 by striking ,state law and all that follows through respecting and inserting this section and relevant ,state and ,federal law 7whether statutory or as recognized by the courts7 respecting2 7,f7 in subparagraph 7,i71 as redesignated by subparagraph 7,c71 by inserting and portable treatment orders before the period at the end2 7,g7 in the flush matter at the end1 by striking 7,c7 and inserting 7,g72 and 7,h7 by adding at the end the following new sentence3 ,nothing in subparagraph 7,d7 or 7,e7 shall be construed to apply to sterilization or abortion42 and 7#b7 in paragraph 7#d7-- 7,a7 by striking written2 7,b7 by striking ,state law and inserting ,state or ,federal law2 and 7,c7 by striking of the ,state2 7#c7 by redesignating paragraph 7#e7 as paragraph 7#f72 7#d7 by inserting after paragraph 7#d7 the following new paragraph3 7#e7 ,in this subsection1 the term portable treatment order means a treatment order designed to document a clinical process that includes shared1 informed medical decisionmaking1 that reflects the individual's goals of care and values1 and that is designed to apply across care settings1 including the home4 2 and 7#e7 by inserting after paragraph 7#f71 as redesignated by paragraph 7#c71 the following new paragraph3 7#g7 ,nothing in this subsection shall permit the ,secretary to seek civil penalties1 including exclusion from participation in the program under this title or the program under title ,,xviii1 against an individual or entity if the individual or entity-- 7,a7 used reasonable efforts to deliver care that is consistent with an individual's goals1 preferences1 and values when addressing decisionmaking for an individual who lacks decisional capacity2 or 7,b7 declined to furnish care in accordance with paragraph 7#c74 4 7c7 ,clarification with respect to advance directives ,section #g of the ,assisted ,suicide ,funding ,restriction ,act of #aiig 7#db ,u4,s4,c4 #addjf7 is amended-- 7#a7 in paragraph 7#a71 by striking or at the end2 and 7#b7 by striking paragraph 7#b7 and inserting the following3 7#b7 to require any provider or organization1 or any employee of such a provider or organization1 to follow or be bound by a request from an individual or legally authorized representative1 an advance directive1 or a portable treatment order that directs the purposeful causing of1 or the purposeful assisting in causing1 the death of any individual1 such as by assisted suicide1 euthanasia1 or mercy killing2 or 7#c7 to allow discrimination against or imposition of penalties on any provider or organization1 or any employee of such a provider or organization1 that refuses1 for any reason1 including an objection based on a religious1 conscience1 or moral objection1 to inform1 counsel1 or in any way participate in the purposeful causing of1 or the purposeful assisting in causing1 the death of any individual1 such as by assisted suicide1 euthanasia1 or mercy killing4 4 7d7 ,effective ,dates 7#a7 ,in general ,subject to paragraph 7#b71 the amendments made by subsections 7a7 and 7b7 shall apply to provider agreements and contracts entered into1 renewed1 or extended under title ,,xviii of the ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq471 and to ,state plans under title ,,xix of such ,act 7#db ,u4,s4,c4 #acif et seq471 on or after such date as the ,secretary of ,health and ,human ,services specifies1 but in no case may such date be later than #a year after the date of the enactment of this ,act4 7#b7 ,extension of effective date for ,state law amendment ,in the case of a ,state plan under title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 which the ,secretary of ,health and ,human ,services determines requires ,state legislation in order for the plan to meet the additional requirements imposed by the amendments made by subsection 7b71 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 the enactment of this ,act4 ,for purposes of the previous sentence1 in the case of a ,state that has a #b-year legislative session1 each year of the session is considered to be a separate regular session of the ,state legislature4 #h4 ,additional requirements for facilities 7a7 ,requirements 7#a7 ,in general ,section #ahff7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7a77#a77 is amended-- 7,a7 in subparagraph 7,v71 by striking and at the end2 7,b7 in subparagraph 7,w71 as added by section #cjje7a77;,c7 of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh71 by redesignating such subparagraph as subparagraph 7,x71 moving such subparagraph to follow subparagraph 7,v71 moving such subparagraph #b ems to the left1 and striking the period at the end and inserting a comma2 7,c7 in subparagraph 7,w71 as added by section #fdjf7;b77#c7 of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh71 by redesignating such subparagraph as subparagraph 7,y71 moving such subparagraph to follow subparagraph 7,x71 as added by subparagraph 7,b71 moving such subparagraph #b ems to the left1 and striking the period at the end and inserting 1 and2 and 7,d7 by inserting after subparagraph 7,y7 the following new subparagraph3 7,z7 in the case of hospitals1 skilled nursing facilities1 home health agencies1 and hospice programs1 to assure that appropriate documentation of care plans made while the individual received care by or through the provider 7which may include advance directives1 portable orders1 or other locally appropriate documents7 be completed prior to discharge to allow the plan to be carried out after discharge4 4 7#b7 ,effective ,date ,the amendments made by this subsection shall apply to agreements entered into or renewed on or after ,january #a1 #bjae4 7b7 ,,hhs study and report 7#a7 ,study ,the ,secretary of ,health and ,human ,services shall conduct a study on the extent to which hospitals1 skilled nursing facilities1 hospice programs1 home health agencies1 and applicable providers of planning services under section #ahfa7;iii7 of the ,social ,security ,act1 as added by section #c7;a71 work with individuals to-- 7,a7 engage in a care planning process2 7,b7 thoroughly and completely document the care planning process in the medical record2 7,c7 complete documents necessary to support the treatment and care plan1 such as portable treatment orders and advance directives2 7,d7 provide services and support that is free from discrimination based on advanced age1 disability status1 or advanced illness2 and 7,e7 provide documentation necessary to carry out the treatment plan to-- 7i7 subsequent providers or facilities2 and 7ii7 the individual1 their legally authorized representatives1 and1 where appropriate and relevant1 their family caregiver4 7#b7 ,report ,not later than ,january #a1 #bjah1 the ,secretary of ,health and ,human ,services shall submit to ,congress a report on the study conducted under paragraph 7#a7 together with recommendations for such legislation and administrative action as the ,secretary determines to be appropriate4 #i4 ,grants for increasing public awareness of advance care planning and advanced illness care 7a7 ,material and resources development 7#a7 ,in general ,the ,secretary of ,health and ,human ,services 7in this section referred to as the ,secretary7 is authorized to award grants to entities described in subsection 7d7 to develop online training modules1 decision support tools1 and instructional materials for individuals1 family caregivers1 and health care providers that include-- 7,a7 for healthy individuals1 the importance of-- 7i7 identifying an individual who will make treatment decisions in the event of future cognitive incapacity2 7ii7 discussing values and goals relevant to catastrophic injury or illness2 and 7iii7 completing an advance directive that-- 7,i7 appoints a surrogate2 and 7,,ii7 documents goals and values and other information that should be considered in making treatment decisions2 7,b7 for individuals with advanced illness1 the importance of-- 7i7 articulating goals of care2 7ii7 understanding prognosis and typical disease trajectory2 7iii7 evaluating treatment options in light of goals of care2 7iv7 developing a treatment plan2 and 7v7 documenting the treatment plan on advance directives1 portable treatment orders1 and other documentation forms used in the locality where the plan is to be executed2 7,c7 the role and effective use of ,state and other advance directive forms and portable treatment orders2 and 7,d7 the range of services for individuals facing advanced illness1 including planning services1 palliative care1 and hospice care4 7#b7 ,period ,any grant awarded under paragraph 7#a7 shall be for a period of #c years4 7b7 ,establishment and maintenance of web- and telephone-,based resources 7#a7 ,in general ,the ,secretary is authorized to award grants to entities described in subsection 7d7 to establish and maintain a website and telephone hotline to disseminate resources developed under subsection 7a7 and materials designed by the ,department of ,health and ,human ,services ,center for ,faith-,based and ,neighborhood ,partnerships for faith communities4 7#b7 ,period ,any grant awarded under paragraph 7#a7 shall be for a period of #e years4 7#c7 ,ability to sustain activities ,the ,secretary shall take into account the ability of an entity to sustain the activities described in paragraph 7#a7 beyond the #e-year grant period in determining whether to award a grant under paragraph 7#a7 to the entity4 7c7 ,national public education campaign 7#a7 ,in general ,the ,secretary is authorized to award grants to entities described in subsection 7d7 to conduct a national public education campaign to raise public awareness of advance care planning and advanced illness care1 including the availability of the resources created under subsections 7a7 and 7b74 7#b7 ,period ,any grant awarded under paragraph 7#a7 shall be for a period of #e years4 7d7 ,eligible entities ,entities described in this subsection are public or private entities 7including ,states or political subdivisions of a ,state1 faith-based organizations1 and religious educational institutions71 or a consortium of any such entities4 7e7 ,authorization of appropriations 7#a7 ,in general ,there are authorized to be appropriated to the ,secretary-- 7,a7 for purposes of making grants under subsection 7a71 #e1jjj1jjj for fiscal year #bjae1 to remain available until expended2 7,b7 for purposes of making grants under subsection 7b71 #e1jjj1jjj for fiscal year #bjae1 to remain available until expended2 and 7,c7 for purposes of making grants under subsection 7c71 #e1jjj1jjj for fiscal year #bjae to remain available until expended4 7#b7 ,limitation ,none of the funds appropriated under paragraph 7#a7 shall be used to-- 7,a7 develop a model advance directive2 7,b7 develop or employ a dollars-per-quality adjusted life year 7or similar measure that discounts the value of a life because of an individual's disability72 or 7,c7 make a grant to a private entity that advocates1 promotes1 or facilitates any item or procedure for which funding is unavailable under the ,assisted ,suicide ,funding ,restriction ,act of #aiig 7,public ,law #aje-ab74 #aj4 ,,hhs study and report on the storage of advance directives 7a7 ,study ,the ,secretary of ,health and ,human ,services shall conduct a study on ,state and regional activities with respect to storing completed advance directives and portable treatment orders4 ,such study shall include an analysis of the practicality and feasibility of establishing a national registry for completed advance directives and portable treatment orders1 taking into consideration the constraints created by the privacy provisions enacted as a result of the ,health ,insurance ,portability and ,accountability ,act of #aiif 7,public ,law #ajd-aia74 7b7 ,report ,not later than ,january #a1 #bjag1 the ,secretary of ,health and ,human ,services shall submit to ,congress a report on the study conducted under subsection 7a7 together with recommendations for such legislation and administrative action as the ,secretary determines to be appropriate4 #aa4 ,,gao study and report on the provisions of1 and amendments made by1 this ,act 7a7 ,study ,the ,comptroller ,general of the ,united ,states 7in this section referred to as the ,comptroller ,general7 shall conduct a study on the provisions of1 and amendments made by1 this ,act1 including the quality 7such as individual and family experience1 individual understanding of treatment choices1 and alignment among individual goals1 values1 and preferences1 the documented care plan1 treatment delivered1 and treatment outcomes7 associated with such provisions and such amendments4 7b7 ,report ,not later than ,january #a1 #bjah1 the ,comptroller ,general shall submit to ,congress a report containing the results of the study conducted under subsection 7a71 together with recommendations for such legislation and administrative action as the ,comptroller ,general determines appropriate4 #ab4 ,consultation with the ,care ,planning ,advisory ,board ,the ,secretary of ,health and ,human ,services shall consult with the ,care ,planning ,advisory ,board established under section #f in order to ensure that every activity carried out under the provisions of1 and amendments made by1 this ,act will help individuals to-- 7#a7 receive education and care that is free from discrimination based on advanced age1 disability status1 or presence of advanced illness2 7#b7 develop plans and receive care that is consistent with each individual's goals1 values and preferences2 and 7#c7 receive an explanation of a range of perspectives on approaches for treating advanced illness1 including disease modifying options1 palliative care that supports individuals from the onset of advanced illness and can be provided at the same time as all other care types1 and hospice care4 #ac4 ,rule of construction ,nothing in the provisions of1 or the amendments made by1 this ,act shall be construed to limit the restrictions of1 or to authorize the use of ,federal funds for any service1 material1 or activity pertaining to an item or service or procedure for which funds are unavailable under1 the ,assisted ,suicide ,funding ,restriction ,act of #aiig 7,public ,law #aje-ab74