I

106TH CONGRESS

2D SESSION H. R. 5153

To amend title XVIII of the Social Security Act to ensure adequate payment

rates for ambulance services, to apply a prudent layperson standard

to the determination of medical necessity for emergency ambulance services, and to recognize the additional costs of providing ambulance services

in rural areas.

IN THE HOUSE OF REPRESENTATIVES

SEPTEMBER 12, 2000

Mr. HOUGHTON (for himself, Mr. MINGE, Mr. STUPAK, and Mrs. KELLY) introduced the following bill; which was referred to the Committee on

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 ensure

adequate payment rates for ambulance services, to apply

a prudent layperson standard to the determination of

medical necessity for emergency ambulance services, and

to recognize the additional costs of providing ambulance

services in rural areas.

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

2 This Act may be cited as the ‘‘Medicare Access to

3 Ambulance Services Act of 2000’’.

4 SEC. 2. PAYMENT RATES.

5 (a) IN GENERAL.—Section 1834(l)(3) of the Social

6 Security Act (42 U.S.C. 1395m(l)(3)) is amended to read

7 as follows:

8 ‘‘(3) PAYMENT RATES.—

9 ‘‘(A) GROUND AND AIR AMBULANCE PAY10 MENT RATES.—Subject to the succeeding provi11 sions of this paragraph, in establishing such fee

12 schedule, the Secretary shall—

13 ‘‘(i) set the payment rates provided

14 under the fee schedule for ground ambu15 lance services furnished under this part

16 during 2001 at a rate based on the aver17 age costs (as determined by the Secretary

18 based on a study performed by an inde19 pendent research organization of such

20 costs, adjusted for inflation if necessary)

21 incurred by full cost ambulance suppliers

22 in providing nonemergency basic life sup23 port ambulance services covered under this

24 title, with adjustments to the rates for

25 other service levels to be determined based
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1 on the rule negotiated in accordance with

2 paragraph (1); and

3 ‘‘(ii) set the payment amounts pro4 vided under the fee schedule for all ambu5 lance services furnished in 2002 and each

6 subsequent year at amounts equal to the

7 payment amounts under the fee schedule

8 for services furnished during the previous

9 year, increased by the percentage increase

10 in the Consumer Price Index for all urban

11 consumers (United States city average) for

12 the 12-month period ending with June of

13 the previous year.

14 ‘‘(B) STUDY AND REPORT ON THE COSTS

15 OF RURAL AMBULANCE SERVICES.—

16 ‘‘(i) STUDY.—The Secretary, in con17 sultation with the Office of Rural Health

18 Policy, shall conduct a study of the means

19 by which rural areas with low population

20 densities can be identified for the purpose

21 of designating areas in which the cost of

22 providing ambulance services would be ex23 pected to be higher than similar services

24 provided in more heavily populated areas

25 because of low usage. Such study shall also
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1 include an analysis of the additional costs

2 of providing ambulance services in areas

3 designated under the previous sentence.

4 ‘‘(ii) REPORT.—Not later than June

5 30, 2001, the Secretary shall submit to

6 Congress a report on the results of the

7 study conducted under this section, to8 gether with a regulation based on that

9 study which adjusts the fee schedule pay10 ment rates for ambulance services provided

11 in low density rural areas based on the in12 creased cost of providing such services in

13 such areas.

14 ‘‘(iii) IMPLEMENTATION OF REGULA15 TION.—The regulation submitted under

16 clause (ii) shall become effective not later

17 than January 1, 2002.

18 ‘‘(C) INTERIM PAYMENTS FOR RURAL

19 GROUND AMBULANCE SERVICES.—Notwith20 standing subparagraph (A)(i) of this paragraph,

21 until such time as the fee schedule established

22 under this subsection is modified by the regula23 tion under subparagraph (B), the amount of

24 payment under this subsection for ground am25 bulance services provided in a rural area (as de-
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1 fined in section 1886(d)(2)(D)) shall be the

2 greater of—

3 ‘‘(i) the amount determined under the

4 fee schedule established under this sub5 section (without regard to any phase-in es6 tablished pursuant to paragraph (2)(E));

7 or

8 ‘‘(ii) the amount that would have been

9 paid for such service if the amendments

10 made by section 4531(b) of the Balanced

11 Budget Act of 1997 had not been enacted;

12 as adjusted for inflation pursuant to subpara13 graph (A)(ii). For purposes of this subpara14 graph, an ambulance trip shall be considered to

15 have been provided in a rural area only if the

16 transportation of the patient originated in a

17 rural area.’’.

18 (b) CONFORMING AMENDMENTS.—Section

19 1833(a)(1) of the Social Security Act (42 U.S.C.

20 1395l(a)(1)) is amended—

21 (1) in subparagraph (R)—

22 (A) by inserting ‘‘except as provided in

23 subparagraph (T),’’ before ‘‘with respect’’; and

24 (B) by striking ‘‘and’’ at the end; and
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1 (2) in subparagraph (S), by striking the semi2 colon at the end and inserting ‘‘, and (T) with re3 spect to ambulance services described in section

4 1834(l)(3)(C), the amount paid shall be 80 percent

5 of the lesser of the actual charge for the services or

6 the amount determined under such section;’’.

7 (c) EFFECTIVE DATE.—The amendments made by

8 this section shall apply with respect to services provided

9 on and after January 1, 2001.

10 SEC. 3. PRUDENT LAYPERSON STANDARD FOR EMERGENCY

11 AMBULANCE SERVICES.

12 (a) IN GENERAL.—Section 1861(s)(7) of the Social

13 Security Act (42 U.S.C. 1395x(s)(7)) is amended by strik14 ing ‘‘regulations;’’ and inserting ‘‘regulations, except that

15 such regulations shall not fail to treat ambulance services

16 as medical and other health services solely because the ul17 timate diagnosis of the individual receiving the ambulance

18 services results in the conclusion that ambulance services

19 were not necessary, as long as the request for ambulance

20 services is made after the sudden onset of a medical condi21 tion that is manifested by symptoms of such sufficient se22 verity, including severe pain, that a prudent layperson,

23 who possesses an average knowledge of health and medi24 cine, could reasonably expect to result, without immediate

25 medical attention, in—
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1 ‘‘(A) placing the individual’s health in seri2 ous jeopardy;

3 ‘‘(B) serious impairment to the individual’s

4 bodily functions; or

5 ‘‘(C) serious dysfunction of any bodily

6 organ or part of the individual;’’.

7 (b) EFFECTIVE DATE.—The amendment made by

8 this section shall apply with respect to services provided

9 on and after the date of enactment of this Act.

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