II

106TH CONGRESS

2D SESSION S. 2858

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 SENATE OF THE UNITED STATES

JULY 13, 2000

Mr. GRAMS 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 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,

3 SECTION 1. SHORT TITLE.

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

5 Ambulance Services Act of 2000’’.
2

•S 2858 IS

1 SEC. 2. PAYMENT RATES.

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

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

4 as follows:

5 ‘‘(3) PAYMENT RATES.—

6 ‘‘(A) GROUND AND AIR AMBULANCE PAY7 MENT RATES.—Subject to the succeeding provi8 sions of this paragraph, in establishing such fee

9 schedule, the Secretary shall—

10 ‘‘(i) set the payment rates provided

11 under the fee schedule for ground ambu12 lance services furnished under this part

13 during 2001 at a rate based on the aver14 age costs (as determined by the Secretary

15 based on a study performed by an inde16 pendent research organization of such

17 costs, adjusted for inflation if necessary)

18 incurred by full cost ambulance suppliers

19 in providing nonemergency basic life sup20 port ambulance services covered under this

21 title, with adjustments to the rates for

22 other service levels to be determined based

23 on the rule negotiated in accordance with

24 paragraph (1); and

25 ‘‘(ii) set the payment amounts pro26 vided under the fee schedule for all ambu-
3

•S 2858 IS

1 lance services furnished in 2002 and each

2 subsequent year at amounts equal to the

3 payment amounts under the fee schedule

4 for services furnished during the previous

5 year, increased by the percentage increase

6 in the Consumer Price Index for all urban

7 consumers (United States city average) for

8 the 12-month period ending with June of

9 the previous year.

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

11 OF RURAL AMBULANCE SERVICES.—

12 ‘‘(i) STUDY.—The Secretary, in con13 sultation with the Office of Rural Health

14 Policy, shall conduct a study of the means

15 by which rural areas with low population

16 densities can be identified for the purpose

17 of designating areas in which the cost of

18 providing ambulance services would be ex19 pected to be higher than similar services

20 provided in more heavily populated areas

21 because of low usage. Such study shall also

22 include an analysis of the additional costs

23 of providing ambulance services in areas

24 designated under the previous sentence.
4

•S 2858 IS

1 ‘‘(ii) REPORT.—Not later than June

2 30, 2001, the Secretary shall submit to

3 Congress a report on the results of the

4 study conducted under this section, to5 gether with a regulation based on that

6 study which adjusts the fee schedule pay7 ment rates for ambulance services provided

8 in low density rural areas based on the in9 creased cost of providing such services in

10 such areas.

11 ‘‘(iii) IMPLEMENTATION OF REGULA12 TION.—The regulation submitted under

13 clause (ii) shall become effective not later

14 than January 1, 2002.

15 ‘‘(C) INTERIM PAYMENTS FOR RURAL

16 GROUND AMBULANCE SERVICES.—Notwith17 standing subparagraph (A)(i) of this paragraph,

18 until such time as the fee schedule established

19 under this subsection is modified by the regula20 tion under subparagraph (B), the amount of

21 payment under this subsection for ground am22 bulance services provided in a rural area (as de23 fined in section 1886(d)(2)(D)) shall be the

24 greater of—
5

•S 2858 IS

1 ‘‘(i) the amount determined under the

2 fee schedule established under this sub3 section (without regard to any phase-in es4 tablished pursuant to paragraph (2)(E));

5 or

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

7 paid for such service if the amendments

8 made by section 4531(b) of the Balanced

9 Budget Act of 1997 had not been enacted;

10 as adjusted for inflation pursuant to subpara11 graph (A)(ii). For purposes of this subpara12 graph, an ambulance trip shall be considered to

13 have been provided in a rural area only if the

14 transportation of the patient originated in a

15 rural area.’’.

16 (b) CONFORMING AMENDMENTS.—Section

17 1833(a)(1) of the Social Security Act (42 U.S.C.

18 1395l(a)(1)) is amended—

19 (1) in subparagraph (R)—

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

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

22 (B) by striking ‘‘and’’ at the end; and

23 (2) in subparagraph (S), by striking the semi24 colon at the end and inserting ‘‘, and (T) with re25 spect to ambulance services described in section
6

•S 2858 IS

1 1834(l)(3)(C), the amount paid shall be 80 percent

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

3 the amount determined under such section;’’.

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

5 this section shall apply with respect to services provided

6 on and after January 1, 2001.

7 SEC. 3. PRUDENT LAYPERSON STANDARD FOR EMERGENCY

8 AMBULANCE SERVICES.

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

10 Security Act (42 U.S.C. 1395x(s)(7)) is amended by strik11 ing ‘‘regulations;’’ and inserting ‘‘regulations, except that

12 such regulations shall not fail to treat ambulance services

13 as medical and other health services solely because the ul14 timate diagnosis of the individual receiving the ambulance

15 services results in the conclusion that ambulance services

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

17 services is made after the sudden onset of a medical condi18 tion that is manifested by symptoms of such sufficient se19 verity, including severe pain, that a prudent layperson,

20 who possesses an average knowledge of health and medi21 cine, could reasonably expect to result, without immediate

22 medical attention, in—

23 ‘‘(A) placing the individual’s health in seri24 ous jeopardy;
7

•S 2858 IS

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

2 bodily functions; or

3 ‘‘(C) serious dysfunction of any bodily

4 organ or part of the individual;’’.

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

6 this section shall apply with respect to services provided

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

Æ