,,ii  #aaf? ,,congress  #a/ ,session    
,s4 #hbi  ,,9 ,,! ,,s5ate ,,( ,,!       
,,unit$ ,,/ates  ,m>* #ad1 #bjai,mr4    
,:iteh\se introduc$ ! foll[+ bill2 :i* 0
 read twice & ref]r$ to ! ,committee on 
,f9ance  ,a ,,bill  ,to am5d title ,,xi 
( ! ,social ,security ,act to aw>d      
coop]ative agreem5ts to improve c>e =   
individuals ) advanc$ illnesses1 & = o!r
 purposes4  #a4 ,%ort title ,?is ,act   
may be cit$ z ! ,remov+ ,b>ri]s to      
,p]son- & ,family-,c5t]$ ,c>e ,act (    
#bjai4  #b4 ,coop]ative agreem5ts to    
improve c>e = individuals ) advanc$     
illnesses  7a7 ,9 g5]al ,section        
#aaae;,a ( ! ,social ,security ,act 7#db
 ,u4,s4,c4 #acae;a7 is am5d$-- 7#a7 9 ! 
la/ s5t5ce ( subp>agraph 7,a7 (         
subsection 7b77#b71 by ins]t+ 1 & !     
model describ$ 9 subsection 7h7 be=e !  
p]iod at ! end2 &  7#b7 by add+ at ! end
 ! foll[+ new subsection3  7h7          
,coop]ative agreem5ts ,to improve c>e = 
individuals ) advanc$ illnesses  7#a7 ,9
 g5]al ,! ,secret>y %all1 act+ ?r\gh !  

,c5t]s = ,m$ic>e  ,m$icaid ,s]vices1    
aw>d up to #ae coop]ative agreem5ts to  
eligible entities ) ! goals (--  7,a7   
address+ gaps 9 community capacity to   
provide high-quality1 p]son- &          
family-c5t]$ c>e2  7,b7 improv+ !       
integration & coord9ation ( cl9ical &   
noncl9ical s]vices2  7,c7 exp&+ access  
to a compreh5sive c>e plann+ process &  
s]vices2 &  7,d7 develop+ & implem5t+   
alt]native paym5t models t provide      
acc\ntability = heal? c>e co/s & quality
 outcomes4  7#b7 ,eligible entity ,9 ?is
 subsection1 ! t]m eligible entity means
 ! foll[+3 7,a7 ,a ,/ate ,m$icaid ag5cy4
  7,b7 ,a ,/ate1 local1 or tribal heal? 
ag5cy4  7,c7 ,an acc\ntable c>e         
organization "u section #ahii or an     
acc\ntable c>e organization model te/$  
"u title ,,xviii or ) respect to su*    
title "u ?is section4  7,d7 ,a ,lead    
,organization 7z def9$ 9 p>agraph 7#i774
  7,e7 ,a quality improvem5t            
organization1 su* z a ,quality          
,innovation ,network-,quality           

,improvem5t ,organization ) a contract  
pursuant to "p ,b ( ?is title4  7#c7    
,application  7,a7 ,9 g5]al ,eligible   
entities seek+ a coop]ative agreem5t "u 
?is subsection %all submit to !         
,secret>y an application1 at su* "t1 & 9
 su* mann] z ! ,secret>y may require4   
,an application mu/ include--  7i7 a li/
 ( p>ticipat+ practition]s1 provid]s (  
s]vices1 community-bas$ organizations1 &
 o!r individuals & entities2  7ii7 a    
description ( ! t>get population or     
populations & geographic s]vice area2   
7iii7 a description ( ! int5d$ uses (   
am\nts aw>d$ "u p>agraph 7#d71 & a plan 
= lev]ag+ exi/+ fund+ s\rces to deliv]  
s]vices to ! t>get population or        
populations2  7iv7 a description ( !    
int5d$ c>e deliv]y model & h[ ! model   
supports high-quality1 p]son- &         
family-c5t]$ c>e2  7v7 a plan =-- 7,i7  
work+ ) community-bas$ organizations1   
includ+ fai?-bas$ organizations & ag+ & 
disability organizations2  7,,ii7       
improv+ community-bas$ supports = family

 c>egiv]s2 &  7,,iii7 increas+ ! numb] (
 individuals )9 ! t>get population or   
populations :o--  7aa7 h communicat$ _! 
wi%es reg>d+ m$ical treatm5t us+ ,/ate  
or locally recogniz$ =ms1 su* z advance 
directives or portable m$ical ord]s2    
7bb7 h compreh5sive c>e plans t are     
concrete & actionable2 &  7cc7 h access 
to community-bas$ palliative c>e        
s]vices2 &  7vi7 o!r in=mation z det]m9$
 appropriate by ! ,secret>y4  7#d7 ,aw>d
 am\nts  7,a7 ,9 g5]al ,! ,secret>y may 
aw>d up to #e1jjj1jjj "u ea* coop]ative 
agreem5t "u ?is subsection4  7,b7 ,use (
 funds ,funds aw>d$ "u a coop]ative     
agreem5t may be us$ = ! foll[+ purposes3
  7i7 ,to develop & implem5t a c>e      
deliv]y model z describ$ 9 p>agraph     
7#e77;,b77i7 & an alt]native paym5t     
model z describ$ 9 p>agraph             
7#e77;,b77ii74  7ii7 ,to conduct        
education & tra9+ = heal? c>e           
pr(essionals1 b5efici>ies & family      
c>egiv]s1 or community-bas$             
organizations 9 me?ods = docum5t+ & %>+ 

an individual's c>e goals1 pref]5ces1 & 
values "u su* model4  7iii7 ,to hire    
/aff to conduct c>e managem5t &         
coord9ation activities z "p ( an        
int]discipl9>y c>e team "u su* model4   
7iv7 ,to support ! developm5t (         
community-bas$ palliative c>e teams & ! 
deliv]y ( relat$ s]vices4  7v7 ,to      
modify1 upgrade1 or pur*ase heal?       
in=mation te*nology1 includ+ te*nologies
 t support data aggregation & analytics1
 electronic ex*ange ( heal? in=mation1  
accessibility ( an individual's         
compreh5sive c>e plan1 or remote        
monitor+ "u su* model4  7vi7 ,to conduct
 o!r activities det]m9$ appropriate by !
 ,secret>y4  7#e7 ,implem5tation  7,a7  
,duration ,ea* coop]ative agreem5t "u   
?is subsection %all be aw>d$ = a p]iod (
 #g ye>s4  7,b7 ,pre-implem5tation p]iod
 ,dur+ ! fir/ #b ye>s ( a coop]ative    
agreem5t1 an aw>dee %all "w ) !         
,secret>y to-- 7i7 develop a c>e deliv]y
 model us+ "o or m ( ! waiv]s & exp&$   
s]vices describ$ 9 p>agraphs 7#g7 &     

7#h72  7ii7 develop an alt]native paym5t
 model2 &  7iii7 id5tify a set ( quality
 measures t w be report$ on annually by 
p>ticipants 9 su* model4  7,c7 ,model   
implem5tation ,beg9n+ ) ! ?ird ye> ( a  
coop]ative agreem5t1 an aw>dee-- 7i7    
%all implem5t ! c>e deliv]y model       
develop$ "u subp>agraph 7,b77i7 & !     
alt]native paym5t model develop$ "u     
subp>agraph 7,b77ii72  7ii7 %all        
annually report data on quality measures
 id5tifi$ "u subp>agraph 7,b77iii7 to ! 
,secret>y2 &  7iii7 may1 9 accordance ) 
p>agraphs 7#g7 & 7#h71 receive waiv]s & 
provide exp&$ s]vices z describ$ 9 su*  
p>agraphs1 respectively1 z "p ( a c>e   
deliv]y model t provides high-quality1  
p]son- & family-c5t]$ c>e to ! t>get    
population or populations4  7#f7        
,notification ,! ,secret>y %all provide 
guidance on notification &              
cont9uity-(-c>e plan requirem5ts 9 !    
ev5t a p>ticipat+ provid] leaves a model
 pursuant to a coop]ative agreem5t "u   
?is subsection4  7#g7 ,waiv] ( c]ta9    

requirem5ts ,9 addition to any waiv]s   
pursuant to subsection 7d77#a71 !       
,secret>y %all include ! foll[+ waiv]s (
 requirem5ts &1 :]e applicable1 p]mit   
,m$ic>e ,advantage organizations        
flexibility to waive su* requirem5ts1 ) 
respect to cov]age (1 & paym5t =1 items 
& s]vices furni%$ to individuals        
pursuant to a coop]ative agreem5t "u ?is
 subsection3  7,a7 ,cov]age ( s]vices   
relat$ to an individual's t]m9al illness
 ,a waiv] ( ! requirem5t describ$ 9     
section #ahab7;d77#b77;,a7 t an         
individual elect+ to receive hospice c>e
 %all be deem$ to h waiv$ all rights to 
h paym5t made "u title ,,xviii ) respect
 to s]vices describ$ 9 clause 7ii77,i7 (
 su* section4  7,b7 ,alt]natives 9      
furni%+ ( home c>e ,) respect to home   
heal? s]vices furni%$ to an individual  
by a home heal? ag5cy1 a waiv] ( !      
requirem5ts describ$ 9 sections         
#ahad7;a77#b7 & #ahce7;a77#b77;,a71 t-- 
7i7 a physician makes ! c]tification 7& 
rec]tification1 :]e su* s]vices are     

provid$ ov] a p]iod ( "t7 z describ$ 9  
su* sections2  7ii7 a plan = furni%+ su*
 s]vices to su* individual is e/abli%$ &
 p]iodically review$ by a physician2    
7iii7 su* s]vices are or 7 furni%$ :ile 
! individual 0 "u ! c>e ( a physician2 &
  7iv7 ! physician docum5ts t !         
individual has _h a face-to-face enc\nt]
 z describ$ 9 su* sections1  provid$ t a
 nurse practition]1 cl9ical nurse       
speciali/1 or physician assi/ant 7z ^?  
t]ms are def9$ 9 section                
#ahfa7;aa77#e771 9 accordance ) ,/ate   
law1 makes su* c]tification &           
rec]tification1 e/abli%es & p]iodically 
reviews su* plan1 has ! individual "u _!
 c>e :5 su* s]vices are or 7 furni%$1 & 
docum5ts su* face-to-face enc\nt]4  7,c7
 ,alt]native c]tification = hospice c>e 
,a waiv] ( ! requirem5ts describ$ 9     
subp>agraphs 7,a7 & 7,b7 ( section      
#ahad7;a77#g7 t an individual's att5d+  
physician & ! m$ical director 7or       
physician memb] ( ! int]discipl9>y gr\p 
describ$ 9 section #ahfa7;dd77#b77;,b77 

( ! hospice program provid+ 7or arrang+ 
=7 ! individual's hospice c>e c]tify t !
 individual is t]m9ally ill &           
p]iodically review ! writt5 plan =      
hospice c>e1 provid$ t su* c]tification 
& review is conduct$ by a nurse         
practition]1 cl9ical nurse speciali/1 or
 physician assi/ant 7z ^? t]ms are def9$
 9 section #ahfa7;aa77#e77 9 accordance 
) ,/ate law4  7,d7 ,cov]age ( skill$    
nurs+ s]vices )\t inpati5t /ay ,)       
respect to ext5d$ c>e s]vices furni%$ to
 an individual by a skill$ nurs+        
facility1 a waiv] ( ! requirem5t        
describ$ 9 section #ahfa7;i7 t an       
individual mu/ h be5 an inpati5t 9 a    
hospital = n less ?an #c consecutive    
days be=e 8 dis*>ge & transf] to !      
skill$ nurs+ facility be=e su* ext5d$   
c>e s]vices may be deem$ po/-hospital   
ext5d$ c>e s]vices4  7,e7 ,cov]age (    
home heal? c>e )\t homeb\nd /atus       
requirem5t ,) respect to home heal?     
s]vices furni%$ to an individual by a   
home heal? ag5cy 7z def9$ 9 section     

#ahfa7o771 a waiv] ( ! requirem5ts      
describ$ 9 sections #ahad7;a77#b77;,c7 &
 #ahce7;a77#b77;,a7 t ! individual is or
 0 conf9$ to 8 or h] home4  7#h7        
,availability ( exp&$ s]vices ,a hospice
 program t p>ticipates 9 an alt]native  
paym5t model pursuant to a coop]ative   
agreem5t "u ?is subsection may receive  
an add-on paym5t1 z det]m9$ by !        
,secret>y1 = furni%+ ! foll[+ s]vices to
 ! t>get population or populations "u   
su* model3  7,a7 ,inpati5t alt]native to
 r\t9e hospice c>e  7i7 ,9 g5]al        
,not)/&+ regulations 9 effect prior to !
 enactm5t ( ?is subsection1 if an       
assessm5t meet+ su* requirem5ts z !     
,secret>y det]m9es appropriate has be5  
made t ! home ( an individual :o is     
c]tifi$ = hospice c>e & has elect$ to   
receive hospice c>e is unsafe or        
unsuitable = ! provision ( su* c>e1 su* 
individual may receive su* c>e 9 an     
inpati5t sett+1 includ+ a hospice       
program t meets ! conditions (          
p>ticipation specifi$ 9 section #dah4aaj

 ( title #db1 ,code ( ,f$]al            
,regulations 7z 9 effect on ! date (    
enactm5t ( ?is subp>agraph71 or a skill$
 nurs+ facility t meets ! /&>ds specifi$
 9 subsections 7b7 & 7e7 ( su* section1 
= ! duration an individual has elect$ to
 receive hospice c>e4 ,! assessm5t      
describ$ 9 ! prec$+ s5t5ce may be       
conduct$ by ! individual's att5d+       
physician1 a nurse practition]1 cl9ical 
nurse speciali/1 or physician assi/ant  
7z ^? t]ms are def9$ 9 section          
#ahfa7;aa77#e771 or ! m$ical director   
7or physician memb] ( ! int]discipl9>y  
gr\p describ$ 9 section                 
#ahfa7;dd77#b77;,b77 ( ! hospice program
 provid+ 7or arrang+ =7 ! individual's  
hospice c>e4  7ii7 ,application (       
limitation on inpati5t c>e days ,=      
purposes ( any limitation on ! numb] (  
total inpati5t c>e days = :i* a hospice 
may receive paym5t1 hospice c>e t is    
provid$ 9 an inpati5t sett+ "u ?is      
subp>agraph 7b w\ld o!rwise be provid$ 9
 an outpati5t sett+7 %all n c\nt t[>ds  

su* limitation4  7,b7 ,home-bas$        
alt]native to inpati5t respite c>e  7i7 
,9 g5]al ,not)/&+ section               
#ahfa7;dd77#a77;,g71 an individual :o is
 c]tifi$ = hospice c>e & has elect$ to  
receive hospice c>e may receive         
%ort-t]m1 home-bas$ respite c>e z an    
alt]native to inpati5t respite c>e4     
7ii7 ,limitations ,! home-bas$ respite  
c>e describ$ 9 clause 7i7 is subject to 
! same limitations t apply to inpati5t  
respite c>e "u section                  
#ahfa7;dd77#a77;,g71 includ+ !          
limitation t respite c>e may be provid$ 
only on an int]mitt5t1 non-r\t9e1 &     
occasional basis & may n be provid$     
consecutively ov] long] ?an #e days4    
7#i7 ,def9itions ,9 ?is subsection3 7,a7
 ,lead ,organization ,! t]m ,lead       
,organization means a cov]$ entity =    
purposes ( compliance ) ! regulations   
promulgat$ "u section #bfd7;c7 ( !      
,heal? ,insurance ,portability &        
,acc\ntability ,act ( #aiif 7#db        
,u4,s4,c4 #acbj;d-#b note7 t w conv5e   

community p>tn]s to coord9ate1 manage1 &
 exp& s]vices = ! t>get population or   
populations & be acc\ntable = co/s &    
quality outcomes "u ! coop]ative        
agreem5t4  7,b7 ,coop]ative agreem5t ,! 
t]m coop]ative agreem5t means an        
agreem5t betwe5 ! ,secret>y & an        
eligible entity "u ?is subsection4  7,c7
 ,physician ,! t]m physician has ! mean+
 giv5 su* t]m 9 section #ahfa7r77#a74   
7,d7 ,practition] ,! t]m practition] has
 ! mean+ giv5 su* t]m 9 section         
#ahdb7;b77#ah77;,c74  7,e7 ,provid] (   
s]vices ,! t]m provid] ( s]vices has !  
mean+ giv5 su* t]m 9 section #ahfa7u74  
7,f7 ,t>get population ,! t]m t>get     
population means individuals :o-- 7i7   
are enroll$ = b5efits "u p>ts ,a & ,b ( 
title ,,xviii1 enroll$ 9 a ,m$ic>e      
,advantage plan "u "p ,c ( su* title1   
enroll$ "u a ,/ate ,m$icaid plan1 or    
dually eligible = b5efits "u titles     
,,xviii & ,,xix2  7ii7 h "o or m advanc$
 *ronic conditions1 z det]m9$ by !      
,secret>y1 su* z late-/age canc]1       

conge/ive he>t failure1 *ronic kidney   
disease1 *ronic ob/ructive pulmon>y     
disease1 g]iatric frailty1 ,alzheim]'s  
disease1 or o!r =ms ( progressive       
dem5tia2 &  7iii7 h demon/rat$-- 7,i7   
evid5ce ( rec5t & progressive cognitive 
impairm5t2 or  7,,ii7 a functional      
limitation requir+ ! assi/ance ( ano!r  
p]son 7su* z an inability to p]=m two or
 m activities ( daily liv+74  4  7b7    
,availability ( fund+ ,section          
#aaae;,a7f77#b7 ( ! ,social ,security   
,act 7#db ,u4,s4,c4 #acae;a7f77#b77 is  
am5d$-- 7#a7 by /rik+ ,out ( am\nts     
appropriat$ & ins]t+ 7,a7 ,out ( am\nts 
appropriat$2 &  7#b7 by add+ at ! end ! 
foll[+ new subp>agraph3  7,b7 ,out ( !  
am\nt appropriat$ "u subp>agraph 7,c7 ( 
p>agraph 7#a71 #ge1jjj1jjj %all be made 
available = ! purpose ( aw>d+ funds "u  
subsection 7h77#d71 :i* %all rema9      
available = su* purpose until exp5d$4  4
  #c4 ,id5tification & developm5t (     
quality measures relat+ to advanc$      
illness c>e ,section #ahij;,a ( !       

,social ,security ,act 7#db ,u4,s4,c4   
#acie;aaa-#a7 is am5d$ by add+ at ! end 
! foll[+ new subsection3  7h7 ,advanc$  
illness c>e quality measures  7#a7 ,9   
g5]al ,! ,secret>y1 9 consultation ) !  
,adm9i/rator ( ! ,c5t]s = ,m$ic>e       
,m$icaid ,s]vices1 ! ,director ( !      
,ag5cy = ,heal?c>e ,rese>* & ,quality1 !
 ,adm9i/rator ( ! ,adm9i/ration =       
,community ,liv+1 & ! entity ) a        
contract "u section #ahij7;a71 %all     
e/abli% a core set ( evid5ce-bas$       
quality measures relat+ to advanc$      
illness c>e4 ,su* quality measures may  
include outcome1 /ructural1 & process   
measures 9 ! foll[+ doma9s3  7,a7 ,p]son
 & family exp]i5ce ( c>e4  7,b7 ,access 
to ne$$ s]vices 7m$ical & supportive71  
su* z home c>e1 palliative c>e1 & timely
 ref]ral to hospice4  7,c7 ,alignm5t (  
c>e ) an individual's pref]5ces1 goals1 
& values4  7,d7 ,scre5+ & treatm5t =    
physical symptoms1 su* z dyspnea1       
nausea1 & con/ipation4  7,e7            
,utilization ( heal? c>e & support      

s]vices4  7,f7 ,%>$ decision mak+ &     
in=m$ cons5t4  7#b7 ,process = id5tify+ 
& develop+ quality measures ,9 id5tify+ 
& develop+ ! quality measures = ! core  
set describ$ 9 p>agraph 7#a71 !         
,secret>y %all take ! foll[+ actions3   
7,a7 ,id5tify exi/+ measures ,id5tify   
exi/+ quality measures relat+ to advanc$
 illness c>e t are 9 use "u public &    
privately sponsor$ heal? c>e            
arrangem5ts4  7,b7 ,developm5t (        
measures ,ent] into grants1 contracts1  
or int]gov]nm5tal agreem5ts ) eligible  
entities = ! purposes ( develop+ quality
 measures 7:i* may include improv+ exi/+
 quality measures7 relat+ to advanc$    
illness c>e t1 to ! ext5t practicable1  
all[ = ! use ( heal? in=mation          
te*nologies 9 collect+ data relat+ to   
su* quality measures4  7,c7 ,/akehold]  
fe$back ,solicit fe$back f a wide array 
( /akehold]s on quality measures to     
include 9 ! core set4  7#c7 ,publication
 & updates  7,a7 ,publication ,n lat]   
?an ,janu>y #a1 #bjbb1 ! ,secret>y %all 

publi% a core set ( quality measures =  
advanc$ illness c>e4  7,b7 ,updates     
,beg9n+ ,janu>y #a1 #bjbd 7& e #b ye>s  
!reaft]71 ! ,secret>y1 9 coord9ation ) !
 entity ) a contract "u section         
#ahij7;a71 %all solicit /akehold]       
fe$back & publi% an updat$ set ( quality
 measures1 prioritiz+ measures t address
 gap areas relat$ to advanc$ illness    
c>e4  7#d7 ,fund+ ,!re are au?oriz$ to  
be appropriat$ su* sums z may be        
necess>y to c>ry out ?is subsection4  4