Sec. 3. Improvement of advanced illness planning and coordination
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Section 1861(s)(2) of the Social Security Act ( 42 U.S.C. 1395x(s)(2) ) is amended— in subparagraph (EE), by striking and at the end; in subparagraph (FF), by inserting and at the end; and by inserting after subparagraph
(FF)the following new paragraph: planning services (as defined in subsection (iii)); . Section 1861 of the Social Security Act ( 42 U.S.C. 1395x ) is amended by adding at the end the following new subsection: The term planning services means a voluntary decisionmaking process that includes the elements described in paragraph
(2)and is furnished to a planning services eligible individual by an applicable provider through an interdisciplinary team. Except as provided in clause (ii), planning services may only be furnished to a planning services eligible individual under this title once in each 12-month period. The Secretary shall establish appropriate exceptions to the frequency limitation under clause (i), such as when there is a change in the individual's medical condition. The elements described in this paragraph are the following: One or more face-to-face encounters between one or more members of the interdisciplinary team and the individual and, at the individual’s discretion, family caregivers, or, for an individual who lacks decisionmaking capacity under State law, the individual’s legally authorized representative. The provision of information about the typical trajectory of illnesses or conditions that affect the individual, 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 incapacity. Assisting the individual in defining and articulating goals of care, values, and preferences. Providing the individual with and discussing information about the benefits and burdens of relevant ranges of treatment options available to the individual, including disease modifying or potentially curative treatment, palliative care, which may be provided alone or in conjunction with disease modifying treatment, and, when the individual may be currently eligible or may become eligible for hospice care due to disease progression. Assisting the individual in evaluating treatment options and approaches to care to identify those that most closely align with the individual’s goals of care, values, and preferences. Preparing, and sharing with relevant providers, documentation— that states the individual’s goals of care, preferences, and values, preferred decisionmaking strategies, and a plan of care that is concrete and actionable; and that is in State or locally recognized forms that are used for the purpose of assuring that providers can follow the plan across care settings, such as advance directives or portable treatment orders. Referrals to providers, including medical and social service providers, who deliver care consistent with the plan. Providing culturally and educationally appropriate training for the individual and family caregivers to support their ability to carry out the plan. Even when the individual’s decisional capacity is impaired and another person or entity, such as an appointed agent, proxy, or surrogate, is exercising legal authority under State law governing decisionmaking on behalf of incapacitated individuals, the interdisciplinary team shall make a reasonable attempt to include the individual in the planning process. For purposes of this subsection, the term planning services eligible individual means an individual that meets at least one of the following criteria: The individual is diagnosed with metastatic or locally advanced cancer. The individual is diagnosed with Alzheimer’s disease or another progressive dementia. The individual is diagnosed with late-stage neuromuscular disease. The individual is diagnosed with late-stage diabetes. The individual is diagnosed with late-stage kidney, liver, heart, gastrointestinal, cerebrovascular, or lung disease. The individual needs assistance with two or more activities of daily living (defined as bathing, dressing, eating, getting out of bed or a chair, mobility, and toileting) not associated with an acute or post-operative conditions that are caused by one or more serious or life threatening illnesses or frailty. The individual meets other criteria determined appropriate by the Secretary, including criteria that are designed to identify individuals with a need for planning services due to a serious or life threatening illness or risk of decline in cognitive function over time. For purposes of this subsection, the term applicable provider means a hospice program (as defined in section 1861(dd)(2)) or other provider of services (as defined in section 1861(u)) or supplier (as defined in section 1861(d)) that— furnishes planning services through an interdisciplinary team; and meets such other requirements the Secretary may determine to be appropriate. For purposes of this subsection, the term interdisciplinary team means a group that— includes the personnel described in subsection (dd)(2)(B)(i); may include a chaplain, minister, or personal religious or spiritual advisor; may include other direct care personnel; and meets requirements that may be established by the Secretary. An applicable provider furnishing planning services to a planning services eligible individual shall offer to the individual (or the individual’s legally authorized representative when the individual has been found to lack decisional capacity) the opportunity to select either a chaplain affiliated with the provider, a minister, or personal religious or spiritual advisor who can help to represent the individual’s goals, values, and preferences to serve as a core team member at the individual’s (or legally authorized representative’s) request. The requirements established by the Secretary under subparagraph (A)(ii) shall include a requirement that interdisciplinary team members (except for the chosen chaplain, minister, or personal religious or spiritual advisor) 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 a serious or life threatening illness. . Section 1848(j)(3) of the Social Security Act ( 42 U.S.C. 1395w–4(j)(3) ) is amended by inserting (2)(GG), after (2)(FF) (including administration of the health risk assessment), . Section 1862(a) of the Social Security Act ( 42 U.S.C. 1395y(a) ) is amended— in paragraph (1)— in subparagraph (O), by striking and at the end; in subparagraph
(P)by striking the semicolon at the end and inserting , and ; and by adding at the end the following new subparagraph: in the case of planning services (as defined in section 1861(iii)(1)), which are furnished more frequently than is covered under subparagraph
(B)of such section; ; and in paragraph (7), by striking or
(P)and inserting (P), or
(Q). The amendments made by this subsection shall apply to services furnished on or after January 1, 2017. Section 1115A(b)(2) of title XI of the Social Security Act ( 42 U.S.C. 1315a(b)(2) ) is amended— in subparagraph (A), by adding at the end the following new sentence: The models selected under this subparagraph shall include the model described in subparagraph
(D)and such model shall be implemented by not later than December 31, 2017. ; and by adding at the end the following new subparagraph: 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 individuals. At least one applicable provider selected for participation under the model shall be a hospice program (as defined in section 1861(dd)(2)). In this subparagraph, the term applicable provider has the meaning given such term in section 1861(iii)(4). In this subparagraph, the term advanced illness care coordination services means the following services: Planning services (as defined in section 1861(iii)). A multi-dimensional assessment of the individual’s strengths and limitations. An assessment of the individual’s formal and informal supports, including family caregivers. Comprehensive medication review and management (including, if appropriate, counseling and self-management support). In-home supportive services for the eligible individual and family caregivers consistent with the care plan. 24-hour access to emergency support in person or via telephone or telemedicine with the individual’s medical record and care plan available to the responder. Coordination across health care and social service systems, including involvement of the interdisciplinary team to evaluate quality and address concerns over time. Such other services as specified by the Secretary. In this subparagraph, the term eligible individual means an individual who— is entitled to, or enrolled for, benefits under part A of title XVIII and enrolled under part B of such title, but not enrolled under part C of such title; and has the need for assistance with two or more activities of daily living (defined as bathing, dressing, eating, getting out of bed or a chair, mobility, and toileting) that is not associated with an acute or post-operative condition that is caused by one or more serious or life threatening conditions or frailty. .
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- 42 USC 1395w–4(j)(3)
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Sec. 3
Improvement of advanced illness planning and coordination
Cite42 USC 1395w–4(j)(3)
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