I 

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. 

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 2014’’. 


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

2 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. 

3 SEC. 2. REFORM TO THE MEDICARE AMBULANCE FEE 

4 SCHEDULE. 

5 (a) IN GENERAL.—Section 1834(l) of the Social Se6 curity Act (42 U.S.C. 1395m(l)) is amended by adding 

7 the following new paragraphs: 

8 ‘‘(16) INCREASE IN CONVERSION FACTOR FOR

9 GROUND AMBULANCE SERVICES.—In the case of 

10 ground ambulance services furnished on or after 

11 April 1, 2015, for purposes of determining the fee 

12 schedule amount for such services under this sub13 section, the conversion factor otherwise applicable to 

14 such services shall be increased by— 

15 ‘‘(A) with respect to ground ambulance 

16 services for which the transportation originates 

17 in a qualified rural area, as identified using the 

18 methodology described in paragraph 

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

20 ‘‘(B) with respect to ground ambulance 

21 services not described in subparagraph (A) and 

22 for which the transportation originates in a 

23 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 ‘‘(17) INCREASE IN MILEAGE RATE FOR

7 GROUND AMBULANCE SERVICES.—In the case of 

8 ground ambulance services furnished on or after 

9 April 1, 2015, for purposes of determining the fee 

10 schedule amount for such services under this sub11 section, the payment rate for mileage otherwise ap12 plicable 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 for which the transportation originates 

20 in a rural area described under paragraph (9) 

21 or in a rural census tract described in such 

22 paragraph, 3 percent; and 

23 ‘‘(C) with respect to ground ambulance 

24 services not described in subparagraph (A) or 

25 (B), 2 percent.’’. 


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1 (b) STUDY AND REPORT.— 

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

3 Human Services shall conduct a study on how the 

4 conversion factor applicable to ground ambulance 

5 services under the ambulance fee schedule under sec6 tion 1834(l) of the Social Security Act (42 U.S.C. 

7 1395m(l)), as adjusted under paragraph (16) of 

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

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

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

11 areas. In determining such costs, the Secretary shall 

12 use the data collected through the data collection 

13 system under paragraph (18) of such section, as 

14 added by section 4. 

15 (2) REPORT.—Not later than January 1, 2019, 

16 the Secretary of Health and Human Services shall 

17 submit to Congress a report on the study conducted 

18 under paragraph (1), together with recommenda19 tions for such legislation and administrative action 

20 as the Secretary determines appropriate. 

21 SEC. 3. PRIOR AUTHORIZATION FOR AMBULANCE TRANS22 PORTS OF ESRD BENEFICIARIES. 

23 (a) IN GENERAL.—Section 1834(l) of the Social Se24 curity Act (42 U.S.C. 1395m(l)), as amended by section 


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1 2, is amended by adding at the end the following new 

2 paragraph: 

3 ‘‘(18) PRIOR AUTHORIZATION OF COVERAGE

4 FOR AMBULANCE TRANSPORTS OF ESRD BENE5 FICIARIES.— 

6 ‘‘(A) PROCESS.— 

7 ‘‘(i) IN GENERAL.—For applicable 

8 ESRD ambulance services furnished on or 

9 after January 1, 2016, by an ambulance 

10 provider, the Secretary shall establish and 

11 implement a process under which the Sec12 retary shall determine, in advance of fur13 nishing such a service to an individual, 

14 whether payment for such service may not 

15 be made because such service is not cov16 ered or because of the application of sec17 tion 1862(a)(1). 

18 ‘‘(ii) DENIAL OF PAYMENT.—Subject 

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

20 shall be made under this part for the serv21 ice unless the Secretary determines pursu22 ant to such process that the service meets 

23 the applicable requirements for coverage. 


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1 ‘‘(B) ELEMENTS OF PROCESS.—The proc2 ess described in subparagraph (A) shall include 

3 the following elements: 

4 ‘‘(i) In order to obtain a prior author5 ization, the ambulance provider shall sub6 mit— 

7 ‘‘(I) a valid physician certifi8 cation statement (PCS) for non-emer9 gency ambulance transport; and 

10 ‘‘(II) any other documentation 

11 determined appropriate by the Sec12 retary. 

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

14 a prior authorization request within 7 busi15 ness days of receiving the request. 

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

17 a prior authorization determination within 

18 7 business days of the date of the Sec19 retary’s receipt of medical documentation 

20 needed to make such determination, sub21 paragraph (A)(ii) shall not apply. 

22 ‘‘(iii) In making the determination 

23 under subparagraph (A) with respect to a 

24 service and individual, the Secretary shall 


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1 evaluate the medical necessity of the serv2 ice by determining— 

3 ‘‘(I) whether the individual is un4 able to get up from bed without as5 sistance, unable to ambulate, and un6 able to sit in a chair or wheelchair; 

7 ‘‘(II) whether the individual has 

8 a medical condition that, regardless of 

9 bed confinement, is such that trans10 port by ambulance is medically nec11 essary; or 

12 ‘‘(III) whether the individual 

13 meets other criteria as determined ap14 propriate by the Secretary. 

15 ‘‘(iv) If the prior authorization re16 quest is approved, such request shall be 

17 retroactive to the date on which such re18 quest was received. 

19 ‘‘(v) An approved prior authorization 

20 shall be valid for a 60-day period. The Sec21 retary may provide for an extension of 

22 such period if the Secretary determines 

23 such an extension is appropriate. 

24 ‘‘(vi) An approved prior authorization 

25 shall be deemed to constitute medical neVerDate Mar 15 2010 22:19 Sep 12, 2014 Jkt 039200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H5460.IH H5460

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1 cessity but shall not eliminate the docu2 mentation requirements necessary to sup3 port a claim for the transport. 

4 ‘‘(vii) Other elements determined ap5 propriate by the Secretary. 

6 ‘‘(C) RELIANCE UPON CONTRACTORS.— 

7 The Secretary may rely upon contractors to im8 plement the requirements of this paragraph. 

9 The contractor’s compensation shall be limited 

10 to a demonstration that it has reduced the 

11 number of non-emergency basic life support 

12 services involving individuals with end-stage 

13 renal disease for renal dialysis services (as de14 scribed in section 1881(b)(14)(B)) furnished 

15 other than on an emergency basis. 

16 ‘‘(D) APPLICABLE ESRD AMBULANCE

17 SERVICES.—In this paragraph, the term ‘appli18 cable ESRD ambulance services’ means ambu19 lance services consisting of non-emergency basic 

20 life support services involving transport of an 

21 individual with end-stage renal disease for renal 

22 dialysis services (as described in section 

23 1881(b)(14)(B)) furnished other than on an 

24 emergency basis. 


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1 ‘‘(E) AMBULANCE PROVIDER.—In this 

2 paragraph, the term ‘ambulance provider’ 

3 means a provider of services (as defined in sec4 tion 1861(u)) or other entity that furnishes am5 bulance services under this title. 

6 ‘‘(F) IMPLEMENTATION.— 

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

8 (ii), the Secretary may carry out this para9 graph through program instruction or oth10 erwise. 

11 ‘‘(ii) SUFFICIENT NOTICE TO PRE12 PARE.—Not later than June 30, 2015, the 

13 Secretary shall make the aspects of the 

14 process under this paragraph available to 

15 the public.’’. 

16 (b) CONFORMING AMENDMENTS.—Section 1834(l) of 

17 the Social Security Act (42 U.S.C. 1395m(l)) is amend18 ed— 

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

20 provider or under arrangement with a provider’’ and 

21 inserting ‘‘an ambulance provider (as defined in 

22 paragraph (18)(E)) or under arrangement with an 

23 ambulance provider’’; 

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

25 subparagraph (B), by striking ‘‘provider or supplier 


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1 of ambulance services’’ and inserting ‘‘ambulance 

2 provider (as defined in paragraph (18)(E))’’; 

3 (3) in paragraph (9), in the heading, by insert4 ing ‘‘AMBULANCE’’ after ‘‘RURAL’’; 

5 (4) in paragraph (12), in the heading, by in6 serting ‘‘AMBULANCE’’ after ‘‘RURAL’’; and 

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

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

9 ‘‘ambulance provider (as defined in paragraph 

10 (18)(E))’’. 

11 SEC. 4. REQUIRING AMBULANCE PROVIDERS TO SUBMIT 

12 COST AND OTHER INFORMATION. 

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

14 1395m(l)), as amended by section 3, is amended by adding 

15 at the end the following new paragraph: 

16 ‘‘(19) SUBMISSION OF COST AND OTHER INFOR17 MATION.— 

18 ‘‘(A) DEVELOPMENT OF DATA COLLECTION

19 SYSTEM.—The Secretary shall develop a data 

20 collection system (which may include use of a 

21 cost survey and standardized definitions) for 

22 providers and suppliers of ambulance services to 

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1 retary. Such system shall be designed to submit 

2 information— 

3 ‘‘(i) needed to evaluate the appro4 priateness of payment rates under this 

5 subsection; 

6 ‘‘(ii) on the utilization of capital 

7 equipment and ambulance capacity; and 

8 ‘‘(iii) on different types of ambulance 

9 services furnished in different geographic 

10 locations, including rural areas and low 

11 population density areas described in para12 graph (12). 

13 ‘‘(B) SPECIFICATION OF DATA COLLEC14 TION SYSTEM.— 

15 ‘‘(i) IN GENERAL.—Not later than 

16 July 1, 2015, the Secretary shall— 

17 ‘‘(I) specify the data collection 

18 system under subparagraph (A) and 

19 the time period during which such 

20 data is required to be submitted; and 

21 ‘‘(II) identify the providers and 

22 suppliers of ambulance services who 

23 would be required to submit the infor24 mation under such data collection sys25 tem. 


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1 ‘‘(ii) RESPONDENTS.—Subject to sub2 paragraph (D)(ii), the Secretary shall de3 termine an appropriate sample of providers 

4 and suppliers of ambulance services to sub5 mit information under the data collection 

6 system for each period for which reporting 

7 of data is required. 

8 ‘‘(C) PENALTY FOR FAILURE TO REPORT

9 COST AND OTHER INFORMATION.—Beginning 

10 on July 1, 2016, a 5-percent reduction to pay11 ments under this part shall be made for a 1- 

12 year prospective period specified by the Sec13 retary to a provider or supplier of ambulance 

14 services who— 

15 ‘‘(i) is identified under subparagraph 

16 (B)(i)(II) as being required to submit the 

17 information under the data collection sys18 tem; and 

19 ‘‘(ii) does not submit such information 

20 during the period specified under subpara21 graph (B)(i)(I). 

22 ‘‘(D) ONGOING DATA COLLECTION.— 

23 ‘‘(i) REVISION OF DATA COLLECTION

24 SYSTEM.—The Secretary may, as deterVerDate Mar 15 2010 22:19 Sep 12, 2014 Jkt 039200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\H5460.IH H5460

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1 mined appropriate, periodically revise the 

2 data collection system. 

3 ‘‘(ii) SUBSEQUENT DATA COLLEC4 TION.—In order to continue to evaluate 

5 the appropriateness of payment rates 

6 under this subsection, the Secretary shall, 

7 for years after 2016 (but not less often 

8 than once every 3 years), require providers 

9 and suppliers of ambulance services to sub10 mit information for a period the Secretary 

11 determines appropriate. The penalty de12 scribed in subparagraph (C) shall apply to 

13 such subsequent data collection periods. 

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

15 consult with stakeholders in carrying out the 

16 development of the system and collection of in17 formation under this paragraph, including the 

18 activities described in subparagraphs (A) and 

19 (D). Such consultation shall include the use of 

20 requests for information and other mechanisms 

21 determined appropriate by the Secretary. 

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

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

24 the collection of information required under this 

25 subsection. 


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1 ‘‘(G) LIMITATIONS ON REVIEW.—There 

2 shall be no administrative or judicial review 

3 under section 1869, section 1878, or otherwise 

4 of the data collection system or identification of 

5 respondents under this paragraph. 

6 ‘‘(H) FUNDING FOR IMPLEMENTATION.— 

7 For purposes of carrying out subparagraph (A), 

8 the Secretary shall provide for the transfer, 

9 from the Federal Supplementary Medical Insur10 ance Trust Fund under section 1841, of 

11 $1,000,000 to the Centers for Medicare & Med12 icaid Services Program Management Account 

13 for fiscal year 2015. Amounts transferred under 

14 this subparagraph shall remain available until 

15 expended.’’. 

Æ 


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