II 

115TH CONGRESS 

1ST SESSION S. 967 

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, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

APRIL 27, 2017 

Ms. STABENOW (for herself, Mr. ROBERTS, Mr. LEAHY, Ms. COLLINS, and 

Mr. SCHUMER) introduced the following bill; which was read twice and 

referred to the Committee on Finance 

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, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Medicare Ambulance Access, Fraud Prevention, and Re6 form Act of 2017’’. 

7 (b) TABLE OF CONTENTS.—The table of contents of 

8 this Act is as follows: 


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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 providers of services and ambulance service providers to submit cost data and other information with respect to ambulance 

services. 

Sec. 5. Treatment of ambulance service providers. 

1 SEC. 2. REFORM TO THE MEDICARE AMBULANCE FEE 

2 SCHEDULE. 

3 (a) IN GENERAL.—Section 1834(l) of the Social Se4 curity Act (42 U.S.C. 1395m(l)) is amended by adding 

5 the following new paragraphs: 

6 ‘‘(17) INCREASE IN CONVERSION FACTOR FOR

7 GROUND AMBULANCE SERVICES.—In the case of 

8 ground ambulance services furnished on or after 

9 January 1, 2018, for purposes of determining the 

10 fee schedule amount for such services under this 

11 subsection, the conversion factor otherwise applica12 ble to such services shall be increased by— 

13 ‘‘(A) with respect to ground ambulance 

14 services for which the transportation originates 

15 in a qualified rural area, as identified using the 

16 methodology described in paragraph 

17 (12)(B)(iii), 25.6 percent; 

18 ‘‘(B) with respect to ground ambulance 

19 services not described in subparagraph (A) and 

20 for which the transportation originates in a 

21 rural area described under paragraph (9) or in 


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1 a rural census tract described in such para2 graph, 3 percent; and 

3 ‘‘(C) with respect to ground ambulance 

4 services not described in subparagraph (A) or 

5 (B), 2 percent. 

6 ‘‘(18) INCREASE IN MILEAGE RATE FOR

7 GROUND AMBULANCE SERVICES.—In the case of 

8 ground ambulance services furnished on or after 

9 January 1, 2018, for purposes of determining the 

10 fee schedule amount for such services under this 

11 subsection, the payment rate for mileage otherwise 

12 applicable to such services shall be increased by— 

13 ‘‘(A) with respect to ground ambulance 

14 services for which the transportation originates 

15 in a qualified rural area, as identified using the 

16 methodology described in paragraph 

17 (12)(B)(iii), 3 percent; 

18 ‘‘(B) with respect to ground ambulance 

19 services not described in subparagraph (A) and 

20 for which the transportation originates in a 

21 rural area described under paragraph (9) or in 

22 a rural census tract described in such para23 graph, 3 percent; and 


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1 ‘‘(C) with respect to ground ambulance 

2 services not described in subparagraph (A) or 

3 (B), 2 percent.’’. 

4 (b) STUDY AND REPORT.— 

5 (1) STUDY.—The Secretary of Health and 

6 Human Services shall conduct a study on how the 

7 conversion factor applicable to ground ambulance 

8 services under the ambulance fee schedule under sec9 tion 1834(l) of the Social Security Act (42 U.S.C. 

10 1395m(l)), as adjusted under paragraph (17) of 

11 such section (as added by subsection (a)), should be 

12 modified, if at all, to take into account the cost of 

13 providing services in urban, rural, and super-rural 

14 areas. In determining such costs, the Secretary shall 

15 use the data collected through the data collection 

16 system under paragraph (20) of such section, as 

17 added by section 4. 

18 (2) REPORT.—Not later than January 1, 2022, 

19 the Secretary of Health and Human Services shall 

20 submit to Congress a report on the study conducted 

21 under paragraph (1), together with recommenda22 tions for such legislation and administrative action 

23 as the Secretary determines appropriate. 


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1 SEC. 3. PRIOR AUTHORIZATION FOR AMBULANCE TRANS2 PORTS OF ESRD BENEFICIARIES. 

3 (a) IN GENERAL.—Section 1834(l) of the Social Se4 curity Act (42 U.S.C. 1395m(l)), as amended by section 

5 2, is amended by adding at the end the following new 

6 paragraph: 

7 ‘‘(19) PRIOR AUTHORIZATION OF COVERAGE

8 FOR AMBULANCE TRANSPORTS OF ESRD BENE9 FICIARIES.— 

10 ‘‘(A) PROCESS.— 

11 ‘‘(i) IN GENERAL.—For applicable 

12 ESRD ambulance services furnished on or 

13 after January 1, 2019, by a provider of 

14 services or an ambulance service provider, 

15 the Secretary shall establish and imple16 ment a process under which the Secretary 

17 shall determine, in advance of furnishing 

18 such a service to an individual, whether 

19 payment for such service may not be made 

20 because such service is not covered or be21 cause of the application of section 

22 1862(a)(1). 

23 ‘‘(ii) DENIAL OF PAYMENT.—Subject 

24 to subparagraph (B)(ii)(II), no payment 

25 shall be made under this part for the serv26 ice unless the Secretary determines pursuVerDate Sep 11 2014 02:22 Apr 29, 2017 Jkt 069200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S967.IS S967

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1 ant to such process that the service meets 

2 the applicable requirements for coverage. 

3 ‘‘(B) ELEMENTS OF PROCESS.—The proc4 ess described in subparagraph (A) shall include 

5 the following elements: 

6 ‘‘(i) In order to obtain a prior author7 ization, the provider of services or ambu8 lance service provider shall submit— 

9 ‘‘(I) a valid physician certifi10 cation statement (PCS) for non-emer11 gency ambulance transport; and 

12 ‘‘(II) any other documentation 

13 determined appropriate by the Sec14 retary. 

15 ‘‘(ii)(I) The Secretary shall respond to 

16 a prior authorization request within 7 busi17 ness days of receiving the request. 

18 ‘‘(II) If the Secretary does not make 

19 a prior authorization determination within 

20 7 business days of the date of the Sec21 retary’s receipt of medical documentation 

22 needed to make such determination, sub23 paragraph (A)(ii) shall not apply. 

24 ‘‘(iii) In making the determination 

25 under subparagraph (A) with respect to a 


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1 service and individual, the Secretary shall 

2 evaluate the medical necessity of the serv3 ice by determining— 

4 ‘‘(I) whether the individual is un5 able to get up from bed without as6 sistance, unable to ambulate, and un7 able to sit in a chair or wheelchair; 

8 ‘‘(II) whether the individual has 

9 a medical condition that, regardless of 

10 bed confinement, is such that trans11 port by ambulance is medically nec12 essary; or 

13 ‘‘(III) whether the individual 

14 meets other criteria as determined ap15 propriate by the Secretary. 

16 ‘‘(iv) If the prior authorization re17 quest is approved, such request shall be 

18 retroactive to the date on which such re19 quest was received. 

20 ‘‘(v) An approved prior authorization 

21 shall be valid for a 60-day period. The Sec22 retary may provide for an extension of 

23 such period if the Secretary determines 

24 such an extension is appropriate. 


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1 ‘‘(vi) An approved prior authorization 

2 shall be deemed to constitute medical ne3 cessity but shall not eliminate the docu4 mentation requirements necessary to sup5 port a claim for the transport. 

6 ‘‘(vii) Other elements determined ap7 propriate by the Secretary. 

8 ‘‘(C) RELIANCE UPON CONTRACTORS.— 

9 The Secretary may rely upon contractors to im10 plement the requirements of this paragraph. 

11 The contractor’s compensation shall be limited 

12 to a demonstration that it has reduced the 

13 number of non-emergency basic life support 

14 services involving individuals with end-stage 

15 renal disease for renal dialysis services (as de16 scribed in section 1881(b)(14)(B)) furnished 

17 other than on an emergency basis. 

18 ‘‘(D) APPLICABLE ESRD AMBULANCE

19 SERVICES.—In this paragraph, the term ‘appli20 cable ESRD ambulance services’ means ambu21 lance services consisting of non-emergency basic 

22 life support services involving transport of an 

23 individual with end-stage renal disease for renal 

24 dialysis services (as described in section 


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1 1881(b)(14)(B)) furnished other than on an 

2 emergency basis. 

3 ‘‘(E) AMBULANCE SERVICE PROVIDER.—In 

4 this paragraph, the term ‘ambulance service 

5 provider’ means an entity that furnishes ambu6 lance services (as described in section 

7 1861(s)(7)) and is not a provider of services (as 

8 defined section 1861(u)). 

9 ‘‘(F) IMPLEMENTATION.— 

10 ‘‘(i) IN GENERAL.—Subject to clause 

11 (ii), the Secretary may carry out this para12 graph through program instruction or oth13 erwise. 

14 ‘‘(ii) SUFFICIENT NOTICE TO PRE15 PARE.—Not later than June 30, 2018, the 

16 Secretary shall make the aspects of the 

17 process under this paragraph available to 

18 the public.’’. 

19 (b) REFERENCES TO AMBULANCE SERVICE PRO20 VIDERS.—Section 1834(l) of the Social Security Act (42 

21 U.S.C. 1395m(l)) is amended— 

22 (1) in paragraph (1), by striking ‘‘a supplier or 

23 provider’’ and inserting ‘‘an ambulance service pro24 vider (as defined in paragraph (19)(E)) or under arVerDate Sep 11 2014 02:22 Apr 29, 2017 Jkt 069200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S967.IS S967

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1 rangement with an ambulance service provider or by 

2 a provider’’; 

3 (2) in paragraph (8), in the matter following 

4 subparagraph (B), by striking ‘‘supplier of ambu5 lance services’’ and inserting ‘‘ambulance service 

6 provider (as defined in paragraph (19)(E))’’; 

7 (3) in paragraph (9), in the heading, by insert8 ing ‘‘PROVIDERS OF SERVICES AND AMBULANCE

9 SERVICE’’ after ‘‘RURAL’’; 

10 (4) in paragraph (12), in the heading, by in11 serting ‘‘PROVIDERS OF SERVICES AND AMBULANCE

12 SERVICE’’ after ‘‘RURAL’’; and 

13 (5) in each of subparagraphs (B)(ii) and (D)(ii) 

14 of paragraph (14), by striking ‘‘entity’’ and inserting 

15 ‘‘provider of services or ambulance service provider 

16 (as defined in paragraph (19)(E))’’. 

17 SEC. 4. REQUIRING PROVIDERS OF SERVICES AND AMBU18 LANCE SERVICE PROVIDERS TO SUBMIT 

19 COST DATA AND OTHER INFORMATION WITH 

20 RESPECT TO AMBULANCE SERVICES. 

21 Section 1834(l) of the Social Security Act (42 U.S.C. 

22 1395m(l)), as amended by section 3, is amended by adding 

23 at the end the following new paragraph: 

24 ‘‘(20) SUBMISSION OF COST DATA AND OTHER

25 INFORMATION.— 


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1 ‘‘(A) DEVELOPMENT OF DATA COLLECTION

2 SYSTEM.— 

3 ‘‘(i) IN GENERAL.—The Secretary 

4 shall develop a data collection system for 

5 the submission by providers of services and 

6 ambulance service providers (as defined in 

7 paragraph (19)(E)) of data on cost, rev8 enue, and utilization with respect to ambu9 lance services, and other information deter10 mined appropriate by the Secretary. Such 

11 system shall enable providers of services 

12 and ambulance service providers to submit 

13 to the Secretary information— 

14 ‘‘(I) needed to evaluate the ap15 propriateness of payment rates under 

16 this subsection; 

17 ‘‘(II) on the utilization of capital 

18 equipment and ambulance capacity; 

19 and 

20 ‘‘(III) on different types of am21 bulance services furnished in different 

22 geographic locations, including rural 

23 areas and low population density 

24 areas described in paragraph (12). 


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1 ‘‘(ii) COLLECTION OF COST DATA IN2 FORMATION.—For purposes of collecting 

3 the cost data information described in sub4 paragraph (B)(iv), the Secretary shall use 

5 the sampling methodology described in 

6 subparagraph (B)(ii). 

7 ‘‘(B) SPECIFICATION OF DATA COLLEC8 TION SYSTEM.— 

9 ‘‘(i) IN GENERAL.—Not later than 90 

10 days after the date of enactment of this 

11 paragraph, the Secretary shall specify the 

12 data collection system developed under 

13 subparagraph (A), which shall consist of 

14 the basic data collection described in clause 

15 (iii) and the cost data information de16 scribed in clause (iv), and the time period 

17 for which the reporting of such data is re18 quired under this paragraph. 

19 ‘‘(ii) SELECTION OF PROVIDERS OF

20 SERVICES AND AMBULANCE SERVICE PRO21 VIDERS REQUIRED TO SUBMIT COST DATA

22 INFORMATION.— 

23 ‘‘(I) IN GENERAL.—Subject to 

24 subparagraph (D)(ii), the Secretary 

25 shall determine a statistically approVerDate Sep 11 2014 02:22 Apr 29, 2017 Jkt 069200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\S967.IS S967

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1 priate sample of providers of services 

2 and ambulance service providers based 

3 upon the organizational designation of 

4 the provider of services or ambulance 

5 service provider as described in clause 

6 (iii)(I) to submit cost data informa7 tion under clause (iv) for each period 

8 for which the reporting of such data is 

9 required, as specified under clause (i). 

10 ‘‘(II) IMPLEMENTATION.—In de11 termining an appropriate sample of 

12 providers of services and ambulance 

13 service providers under subclause (I), 

14 the Secretary shall promulgate an in15 terim final rule and shall accept and 

16 consider public comments on the in17 terim final rule for 30 days after the 

18 date of publication of such interim 

19 final rule. 

20 ‘‘(III) NOTIFICATION OF PRO21 VIDERS OF SERVICES AND AMBU22 LANCE SERVICE PROVIDERS SE23 LECTED.—Not later than 180 days 

24 after the date on which the Secretary 

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1 tion under clause (iii), the Secretary 

2 shall provide notice to those providers 

3 of services and ambulance service pro4 viders selected under this clause to 

5 submit cost data information under 

6 clause (iv). 

7 ‘‘(iii) BASIC DATA COLLECTION.—The 

8 Secretary shall require providers of serv9 ices and ambulance service providers to 

10 submit information under the data collec11 tion system under this paragraph, such as 

12 the following with respect to the provider 

13 of services or ambulance service provider, 

14 not later than the date that is 120 days 

15 after the date on which the Secretary 

16 specifies such data collection system under 

17 clause (i), and not less often than once 

18 every 5 years thereafter: 

19 ‘‘(I) The organizational designa20 tion of the provider of services or am21 bulance service provider as a govern22 ment ambulance authority, inde23 pendent ambulance company, public 

24 safety or fire department-based orgaVerDate Sep 11 2014 02:22 Apr 29, 2017 Jkt 069200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\S967.IS S967

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1 nization, hospital-based organization, 

2 or other type of organization. 

3 ‘‘(II) The percentage of volunteer 

4 emergency medical technician labor 

5 the provider of services or ambulance 

6 service provider relies on. 

7 ‘‘(III) The volume of ambulance 

8 services furnished per year. 

9 ‘‘(IV) The percentage of emer10 gency and non-emergency services fur11 nished under this title per year. 

12 ‘‘(V) The average duration of 

13 transports. 

14 ‘‘(VI) Whether the provider of 

15 services or ambulance service provider 

16 has a sole source contract and the 

17 percentage of the activity provided 

18 under that contract. 

19 ‘‘(VII) Whether the provider of 

20 services or ambulance service provider 

21 is required to pay fees to the local ju22 risdiction to subsidize emergency and 

23 other services as a requirement of 

24 doing business. 


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1 ‘‘(VIII) The percentage of trans2 ports that are urban, rural, or in a 

3 low-population density area described 

4 in paragraph (12), as determined by 

5 the Secretary. 

6 ‘‘(IX) Other data elements that 

7 the Secretary, in consultation with 

8 stakeholders, determines appropriate. 

9 ‘‘(iv) COST DATA INFORMATION.—The 

10 Secretary shall require those providers of 

11 services and ambulance service providers 

12 selected under clause (ii) to submit under 

13 the data collection system under this para14 graph for each period for which the report15 ing of such data is required, as specified 

16 under clause (i), data on cost, revenue, and 

17 utilization, such as— 

18 ‘‘(I) data on total revenue, in19 cluding revenues under this title, sub20 scription programs, Medicaid, other 

21 health care plans and self-pay, public 

22 funding, fundraising and donations, 

23 uncompensated care, and write-offs; 

24 and 


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1 ‘‘(II) data on total cost including 

2 labor costs (paid and volunteer), oper3 ating costs, administrative costs, vehi4 cle and fleet costs, communications 

5 costs, equipment and supplies (includ6 ing drugs), maintenance, building and 

7 facility costs, administrative costs, 

8 local jurisdiction costs, the cost of 

9 readiness, and central office adminis10 tration costs. 

11 ‘‘(C) PENALTY FOR FAILURE TO REPORT

12 COST DATA INFORMATION.— 

13 ‘‘(i) IN GENERAL.—Beginning on Jan14 uary 1, 2021, subject to clause (ii), a 5- 

15 percent reduction to payments under this 

16 part shall be made for a 1-year prospective 

17 period specified by the Secretary to a pro18 vider of services or ambulance service pro19 vider who— 

20 ‘‘(I) is identified under subpara21 graph (B)(ii) or (D)(ii) as being re22 quired to submit information under 

23 subparagraph (B)(iv) or (D)(ii), re24 spectively; and 


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1 ‘‘(II) does not submit such infor2 mation in a timely manner for the pe3 riod specified under subparagraph 

4 (B)(i) or (D)(ii), respectively. 

5 ‘‘(ii) EXCEPTION.—The Secretary 

6 may suspend the payment reduction under 

7 clause (i) with respect to a period in the 

8 event of a natural disaster, bankruptcy, or 

9 other similar situation that the Secretary 

10 determines interfered with ability of the 

11 provider of services or ambulance service 

12 provider to submit such information in a 

13 timely manner for the specified period. 

14 ‘‘(D) ONGOING COST DATA COLLECTION.— 

15 ‘‘(i) REVISION OF DATA COLLECTION

16 SYSTEM.—The Secretary may, as appro17 priate, periodically revise the data collec18 tion system under this paragraph. 

19 ‘‘(ii) SUBSEQUENT COST DATA COL20 LECTION.— 

21 ‘‘(I) IN GENERAL.—In order to 

22 continue to evaluate the appropriate23 ness of payment rates under this sub24 section, the Secretary shall, for years 

25 after 2020 (but not more frequently 


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1 than once every 3 years), require pro2 viders of services and ambulance serv3 ice providers to submit information 

4 described in subparagraph (B)(iv) for 

5 a period the Secretary determines ap6 propriate. The penalty described in 

7 subparagraph (C) shall apply to each 

8 such subsequent data collection period 

9 in accordance with such subpara10 graph. 

11 ‘‘(II) SAMPLE.—For each period 

12 described in subclause (I), the Sec13 retary shall determine a statistically 

14 appropriate sample of providers of 

15 services and ambulance services pro16 viders to submit information under 

17 the data collection system for the pe18 riod. In determining which providers 

19 of services and ambulance service pro20 viders would be required to submit in21 formation for such period, the Sec22 retary may not require a provider of 

23 services or ambulance service provider 

24 who has already submitted informa25 tion for a previous period to submit 


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1 information for a subsequent period 

2 unless all of the providers of services 

3 and ambulance service providers that 

4 the Secretary determines are of the 

5 same type as such provider of services 

6 or ambulance service provider have ei7 ther submitted information or been 

8 penalized under subparagraph (C) for 

9 failing to do so in a timely manner. 

10 ‘‘(E) CONSULTATION.—The Secretary shall 

11 consult with stakeholders in carrying out the 

12 development of the data collection system and 

13 the collection of information under this para14 graph, including the activities described in sub15 paragraphs (A) and (D). Such consultation 

16 shall include the use of requests for information 

17 and other mechanisms determined appropriate 

18 by the Secretary. 

19 ‘‘(F) ADMINISTRATION.—Chapter 35 of 

20 title 44, United States Code, shall not apply to 

21 the collection of information required under this 

22 paragraph. 

23 ‘‘(G) LIMITATIONS ON REVIEW.—There 

24 shall be no administrative or judicial review 

25 under section 1869, section 1878, or otherwise 


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1 of the data collection system under this para2 graph, the determination of providers of serv3 ices and ambulance service providers required 

4 to submit information under the data collection 

5 system, or the application of the penalty for 

6 failure to report information under subpara7 graph (C). 

8 ‘‘(H) FUNDING FOR IMPLEMENTATION.— 

9 For purposes of carrying out subparagraph (A), 

10 the Secretary shall provide for the transfer, 

11 from the Federal Supplementary Medical Insur12 ance Trust Fund under section 1841, of 

13 $1,000,000 to the Centers for Medicare & Med14 icaid Services Program Management Account 

15 for fiscal year 2016. Amounts transferred under 

16 this subparagraph shall remain available until 

17 expended.’’. 

18 SEC. 5. TREATMENT OF AMBULANCE SERVICE PROVIDERS. 

19 (a) IN GENERAL.—Section 1834 of the Social Secu20 rity Act (42 U.S.C. 1395m(l)), as amended by section 4, 

21 is amended by adding at the end the following new para22 graph: 

23 ‘‘(21) TREATMENT OF AMBULANCE SERVICE

24 PROVIDERS AS PROVIDERS OF SERVICES FOR CER25 TAIN PURPOSES.— 


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1 ‘‘(A) PROVIDER REIMBURSEMENT REVIEW

2 BOARD.—For purposes of section 1878, an am3 bulance service provider (as defined in para4 graph (19)(E)) shall be treated as a provider of 

5 services. 

6 ‘‘(B) ESTABLISHMENT OF CONDITIONS OF

7 PARTICIPATION.—An ambulance service pro8 vider— 

9 ‘‘(i) for purposes of section 

10 1865(a)(1), shall be treated as a provider 

11 entity; and 

12 ‘‘(ii) shall be required to meet such 

13 requirements for participation under this 

14 title as the Secretary shall establish by 

15 regulation. 

16 ‘‘(C) USE OF BILLING CODES.—An ambu17 lance service provider may, for purposes of this 

18 title, use billing codes established for providers 

19 of services, if such use is consistent with appli20 cable Federal, State, or local scope of practice 

21 requirements.’’. 

22 (b) EFFECTIVE DATE.—The amendment made this 

23 section shall take effect on January 1, 2018, and shall 


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1 apply to an ambulance service provider on or after such 

2 date. 

Æ 


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