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[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[S. 377 Introduced in Senate (IS)]

114th CONGRESS
  1st Session
                                 S. 377

 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

                            February 4, 2015

  Mr. Schumer (for himself, Mr. Roberts, Mr. Leahy, and Ms. Collins) 
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.

    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 2015''.
    (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 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.''.
    (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, 2020, 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, 2017, by an applicable 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 applicable 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; applicable ambulance 
                provider defined.--In this paragraph:
                            ``(i) Ambulance provider.--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.
                            ``(ii) Applicable ambulance provider.--The 
                        term `applicable ambulance provider' means an 
                        ambulance provider (other than an ambulance 
                        provider who is a provider of services (as 
                        defined in such section)).
                    ``(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, 2016, 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)(i)) 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)(i))'';
            (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)(i))''.

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 ambulance providers 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, 
                        2016, 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 ambulance 
                                providers 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 ambulance 
                        providers 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, 2017, a 5-percent 
                reduction to payments under this part shall be made for 
                a 1-year prospective period specified by the Secretary 
                to an ambulance provider who--
                            ``(i) is identified under subparagraph 
                        (B)(i)(II) or (D)(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.--
                                    ``(I) In general.--In order to 
                                continue to evaluate the 
                                appropriateness of payment rates under 
                                this subsection, the Secretary shall, 
                                for years after 2017 (but not less 
                                often than once every 3 years), require 
                                ambulance providers to submit 
                                information for a period the Secretary 
                                determines appropriate. The penalty 
                                described in subparagraph (C) shall 
                                apply to such subsequent data 
                                collection periods.
                                    ``(II) Sample.--For each period 
                                described in subclause (I), the 
                                Secretary shall determine an 
                                appropriate sample of ambulance 
                                providers to submit information under 
                                the data collection system for such 
                                period. In determining which ambulance 
                                providers would be required to submit 
                                information for such period, the 
                                Secretary may not require an ambulance 
                                provider who has already submitted 
                                information for a previous period to 
                                submit information for a subsequent 
                                period unless all of the ambulance 
                                providers who the Secretary determines 
                                are the same type as such ambulance 
                                provider have either submitted 
                                information or been penalized under 
                                subparagraph (C) for not doing so.
                    ``(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) Definition of ambulance provider.--In this 
                paragraph, the term `ambulance provider' has the 
                meaning given such term in paragraph (18)(E)(i).
                    ``(G) Administration.--Chapter 35 of title 44, 
                United States Code, shall not apply to the collection 
                of information required under this subsection.
                    ``(H) 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.
                    ``(I) 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 2016. Amounts transferred under this 
                subparagraph shall remain available until expended.''.
                                 <all>
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