[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5460 Introduced in House (IH)]

113th CONGRESS
  2d Session
                                H. R. 5460

 To amend title XVIII of the Social Security Act to increase access to 
 ambulance services under the Medicare program and to reform payments 
                 for such services under such program.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           September 11, 2014

Mr. Walden (for himself, Mr. Welch, Mr. Nunes, and Mr. Neal) introduced 
 the following bill; which was referred to the Committee on Energy and 
  Commerce, and in addition to the Committee on Ways and Means, for a 
 period to be subsequently determined by the Speaker, in each case for 
consideration of such provisions as fall within the jurisdiction of the 
                          committee concerned

_______________________________________________________________________

                                 A BILL


 
 To amend title XVIII of the Social Security Act to increase access to 
 ambulance services under the Medicare program and to reform payments 
                 for such services under such program.

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

SECTION 1. SHORT TITLE.

    (a) Short Title.--This Act may be cited as the ``Medicare Ambulance 
Access, Fraud Prevention, and Reform Act of 2014''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title.
Sec. 2. Reform to the Medicare ambulance fee schedule.
Sec. 3. Prior authorization for ambulance transports of ESRD 
                            beneficiaries.
Sec. 4. Requiring ambulance providers to submit cost and other 
                            information.

SEC. 2. REFORM TO THE MEDICARE AMBULANCE FEE SCHEDULE.

    (a) In General.--Section 1834(l) of the Social Security Act (42 
U.S.C. 1395m(l)) is amended by adding the following new paragraphs:
            ``(16) Increase in conversion factor for ground ambulance 
        services.--In the case of ground ambulance services furnished 
        on or after April 1, 2015, for purposes of determining the fee 
        schedule amount for such services under this subsection, the 
        conversion factor otherwise applicable to such services shall 
        be increased by--
                    ``(A) with respect to ground ambulance services for 
                which the transportation originates in a qualified 
                rural area, as identified using the methodology 
                described in paragraph (12)(B)(iii), 25.6 percent;
                    ``(B) with respect to ground ambulance services not 
                described in subparagraph (A) and for which the 
                transportation originates in a rural area described 
                under paragraph (9) or in a rural census tract 
                described in such paragraph, 3 percent; and
                    ``(C) with respect to ground ambulance services not 
                described in subparagraph (A) or (B), 2 percent.
            ``(17) Increase in mileage rate for ground ambulance 
        services.--In the case of ground ambulance services furnished 
        on or after April 1, 2015, for purposes of determining the fee 
        schedule amount for such services under this subsection, the 
        payment rate for mileage otherwise applicable to such services 
        shall be increased by--
                    ``(A) with respect to ground ambulance services for 
                which the transportation originates in a qualified 
                rural area, as identified using the methodology 
                described in paragraph (12)(B)(iii), 3 percent;
                    ``(B) with respect to ground ambulance services for 
                which the transportation originates in a rural area 
                described under paragraph (9) or in a rural census 
                tract described in such paragraph, 3 percent; and
                    ``(C) with respect to ground ambulance services not 
                described in subparagraph (A) or (B), 2 percent.''.
    (b) Study and Report.--
            (1) Study.--The Secretary of Health and Human Services 
        shall conduct a study on how the conversion factor applicable 
        to ground ambulance services under the ambulance fee schedule 
        under section 1834(l) of the Social Security Act (42 U.S.C. 
        1395m(l)), as adjusted under paragraph (16) of such section (as 
        added by subsection (a)), should be modified, if at all, to 
        take into account the cost of providing services in urban, 
        rural, and super-rural areas. In determining such costs, the 
        Secretary shall use the data collected through the data 
        collection system under paragraph (18) of such section, as 
        added by section 4.
            (2) Report.--Not later than January 1, 2019, the Secretary 
        of Health and Human Services shall submit to Congress a report 
        on the study conducted under paragraph (1), together with 
        recommendations for such legislation and administrative action 
        as the Secretary determines appropriate.

SEC. 3. PRIOR AUTHORIZATION FOR AMBULANCE TRANSPORTS OF ESRD 
              BENEFICIARIES.

    (a) In General.--Section 1834(l) of the Social Security Act (42 
U.S.C. 1395m(l)), as amended by section 2, is amended by adding at the 
end the following new paragraph:
            ``(18) Prior authorization of coverage for ambulance 
        transports of esrd beneficiaries.--
                    ``(A) Process.--
                            ``(i) In general.--For applicable ESRD 
                        ambulance services furnished on or after 
                        January 1, 2016, by an ambulance provider, the 
                        Secretary shall establish and implement a 
                        process under which the Secretary shall 
                        determine, in advance of furnishing such a 
                        service to an individual, whether payment for 
                        such service may not be made because such 
                        service is not covered or because of the 
                        application of section 1862(a)(1).
                            ``(ii) Denial of payment.--Subject to 
                        subparagraph (B)(ii)(II), no payment shall be 
                        made under this part for the service unless the 
                        Secretary determines pursuant to such process 
                        that the service meets the applicable 
                        requirements for coverage.
                    ``(B) Elements of process.--The process described 
                in subparagraph (A) shall include the following 
                elements:
                            ``(i) In order to obtain a prior 
                        authorization, the ambulance provider shall 
                        submit--
                                    ``(I) a valid physician 
                                certification statement (PCS) for non-
                                emergency ambulance transport; and
                                    ``(II) any other documentation 
                                determined appropriate by the 
                                Secretary.
                            ``(ii)(I) The Secretary shall respond to a 
                        prior authorization request within 7 business 
                        days of receiving the request.
                            ``(II) If the Secretary does not make a 
                        prior authorization determination within 7 
                        business days of the date of the Secretary's 
                        receipt of medical documentation needed to make 
                        such determination, subparagraph (A)(ii) shall 
                        not apply.
                            ``(iii) In making the determination under 
                        subparagraph (A) with respect to a service and 
                        individual, the Secretary shall evaluate the 
                        medical necessity of the service by 
                        determining--
                                    ``(I) whether the individual is 
                                unable to get up from bed without 
                                assistance, unable to ambulate, and 
                                unable to sit in a chair or wheelchair;
                                    ``(II) whether the individual has a 
                                medical condition that, regardless of 
                                bed confinement, is such that transport 
                                by ambulance is medically necessary; or
                                    ``(III) whether the individual 
                                meets other criteria as determined 
                                appropriate by the Secretary.
                            ``(iv) If the prior authorization request 
                        is approved, such request shall be retroactive 
                        to the date on which such request was received.
                            ``(v) An approved prior authorization shall 
                        be valid for a 60-day period. The Secretary may 
                        provide for an extension of such period if the 
                        Secretary determines such an extension is 
                        appropriate.
                            ``(vi) An approved prior authorization 
                        shall be deemed to constitute medical necessity 
                        but shall not eliminate the documentation 
                        requirements necessary to support a claim for 
                        the transport.
                            ``(vii) Other elements determined 
                        appropriate by the Secretary.
                    ``(C) Reliance upon contractors.--The Secretary may 
                rely upon contractors to implement the requirements of 
                this paragraph. The contractor's compensation shall be 
                limited to a demonstration that it has reduced the 
                number of non-emergency basic life support services 
                involving individuals with end-stage renal disease for 
                renal dialysis services (as described in section 
                1881(b)(14)(B)) furnished other than on an emergency 
                basis.
                    ``(D) Applicable esrd ambulance services.--In this 
                paragraph, the term `applicable ESRD ambulance 
                services' means ambulance services consisting of non-
                emergency basic life support services involving 
                transport of an individual with end-stage renal disease 
                for renal dialysis services (as described in section 
                1881(b)(14)(B)) furnished other than on an emergency 
                basis.
                    ``(E) Ambulance provider.--In this paragraph, the 
                term `ambulance provider' means a provider of services 
                (as defined in section 1861(u)) or other entity that 
                furnishes ambulance services under this title.
                    ``(F) Implementation.--
                            ``(i) In general.--Subject to clause (ii), 
                        the Secretary may carry out this paragraph 
                        through program instruction or otherwise.
                            ``(ii) Sufficient notice to prepare.--Not 
                        later than June 30, 2015, the Secretary shall 
                        make the aspects of the process under this 
                        paragraph available to the public.''.
    (b) Conforming Amendments.--Section 1834(l) of the Social Security 
Act (42 U.S.C. 1395m(l)) is amended--
            (1) in paragraph (1), by striking ``a supplier or provider 
        or under arrangement with a provider'' and inserting ``an 
        ambulance provider (as defined in paragraph (18)(E)) or under 
        arrangement with an ambulance provider'';
            (2) in paragraph (8), in the matter following subparagraph 
        (B), by striking ``provider or supplier of ambulance services'' 
        and inserting ``ambulance provider (as defined in paragraph 
        (18)(E))'';
            (3) in paragraph (9), in the heading, by inserting 
        ``ambulance'' after ``rural'';
            (4) in paragraph (12), in the heading, by inserting 
        ``ambulance'' after ``rural''; and
            (5) in each of subparagraphs (B)(ii) and (D)(ii) of 
        paragraph (14), by striking ``entity'' and inserting 
        ``ambulance provider (as defined in paragraph (18)(E))''.

SEC. 4. REQUIRING AMBULANCE PROVIDERS TO SUBMIT COST AND OTHER 
              INFORMATION.

    Section 1834(l) of the Social Security Act (42 U.S.C. 1395m(l)), as 
amended by section 3, is amended by adding at the end the following new 
paragraph:
            ``(19) Submission of cost and other information.--
                    ``(A) Development of data collection system.--The 
                Secretary shall develop a data collection system (which 
                may include use of a cost survey and standardized 
                definitions) for providers and suppliers of ambulance 
                services to collect cost, revenue, utilization, and 
                other information determined appropriate by the 
                Secretary. Such system shall be designed to submit 
                information--
                            ``(i) needed to evaluate the 
                        appropriateness of payment rates under this 
                        subsection;
                            ``(ii) on the utilization of capital 
                        equipment and ambulance capacity; and
                            ``(iii) on different types of ambulance 
                        services furnished in different geographic 
                        locations, including rural areas and low 
                        population density areas described in paragraph 
                        (12).
                    ``(B) Specification of data collection system.--
                            ``(i) In general.--Not later than July 1, 
                        2015, the Secretary shall--
                                    ``(I) specify the data collection 
                                system under subparagraph (A) and the 
                                time period during which such data is 
                                required to be submitted; and
                                    ``(II) identify the providers and 
                                suppliers of ambulance services who 
                                would be required to submit the 
                                information under such data collection 
                                system.
                            ``(ii) Respondents.--Subject to 
                        subparagraph (D)(ii), the Secretary shall 
                        determine an appropriate sample of providers 
                        and suppliers of ambulance services to submit 
                        information under the data collection system 
                        for each period for which reporting of data is 
                        required.
                    ``(C) Penalty for failure to report cost and other 
                information.--Beginning on July 1, 2016, a 5-percent 
                reduction to payments under this part shall be made for 
                a 1-year prospective period specified by the Secretary 
                to a provider or supplier of ambulance services who--
                            ``(i) is identified under subparagraph 
                        (B)(i)(II) as being required to submit the 
                        information under the data collection system; 
                        and
                            ``(ii) does not submit such information 
                        during the period specified under subparagraph 
                        (B)(i)(I).
                    ``(D) Ongoing data collection.--
                            ``(i) Revision of data collection system.--
                        The Secretary may, as determined appropriate, 
                        periodically revise the data collection system.
                            ``(ii) Subsequent data collection.--In 
                        order to continue to evaluate the 
                        appropriateness of payment rates under this 
                        subsection, the Secretary shall, for years 
                        after 2016 (but not less often than once every 
                        3 years), require providers and suppliers of 
                        ambulance services to submit information for a 
                        period the Secretary determines appropriate. 
                        The penalty described in subparagraph (C) shall 
                        apply to such subsequent data collection 
                        periods.
                    ``(E) Consultation.--The Secretary shall consult 
                with stakeholders in carrying out the development of 
                the system and collection of information under this 
                paragraph, including the activities described in 
                subparagraphs (A) and (D). Such consultation shall 
                include the use of requests for information and other 
                mechanisms determined appropriate by the Secretary.
                    ``(F) Administration.--Chapter 35 of title 44, 
                United States Code, shall not apply to the collection 
                of information required under this subsection.
                    ``(G) Limitations on review.--There shall be no 
                administrative or judicial review under section 1869, 
                section 1878, or otherwise of the data collection 
                system or identification of respondents under this 
                paragraph.
                    ``(H) Funding for implementation.--For purposes of 
                carrying out subparagraph (A), the Secretary shall 
                provide for the transfer, from the Federal 
                Supplementary Medical Insurance Trust Fund under 
                section 1841, of $1,000,000 to the Centers for Medicare 
                & Medicaid Services Program Management Account for 
                fiscal year 2015. Amounts transferred under this 
                subparagraph shall remain available until expended.''.
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