II 

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. 

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 2015’’. 

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 ambulance providers to submit cost and other information. 

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 ‘‘(16) INCREASE IN CONVERSION FACTOR 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 conversion factor otherwise applicable to 

12 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 

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 ‘‘(17) INCREASE IN MILEAGE RATE FOR

5 GROUND AMBULANCE SERVICES.—In the case of 

6 ground ambulance services furnished on or after 

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

8 schedule amount for such services under this sub9 section, the payment rate for mileage otherwise ap10 plicable to such services shall be increased by— 

11 ‘‘(A) with respect to ground ambulance 

12 services for which the transportation originates 

13 in a qualified rural area, as identified using the 

14 methodology described in paragraph 

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

16 ‘‘(B) with respect to ground ambulance 

17 services not described in subparagraph (A) and 

18 for which the transportation originates in a 

19 rural area described under paragraph (9) or in 

20 a rural census tract described in such para21 graph, 3 percent; and 

22 ‘‘(C) with respect to ground ambulance 

23 services not described in subparagraph (A) or 

24 (B), 2 percent.’’. 

25 (b) STUDY AND REPORT.— 


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

2 Human Services shall conduct a study on how the 

3 conversion factor applicable to ground ambulance 

4 services under the ambulance fee schedule under sec5 tion 1834(l) of the Social Security Act (42 U.S.C. 

6 1395m(l)), as adjusted under paragraph (16) of 

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

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

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

10 areas. In determining such costs, the Secretary shall 

11 use the data collected through the data collection 

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

13 added by section 4. 

14 (2) REPORT.—Not later than January 1, 2020, 

15 the Secretary of Health and Human Services shall 

16 submit to Congress a report on the study conducted 

17 under paragraph (1), together with recommenda18 tions for such legislation and administrative action 

19 as the Secretary determines appropriate. 

20 SEC. 3. PRIOR AUTHORIZATION FOR AMBULANCE TRANS21 PORTS OF ESRD BENEFICIARIES. 

22 (a) IN GENERAL.—Section 1834(l) of the Social Se23 curity Act (42 U.S.C. 1395m(l)), as amended by section 

24 2, is amended by adding at the end the following new 

25 paragraph: 


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1 ‘‘(18) PRIOR AUTHORIZATION OF COVERAGE

2 FOR AMBULANCE TRANSPORTS OF ESRD BENE3 FICIARIES.— 

4 ‘‘(A) PROCESS.— 

5 ‘‘(i) IN GENERAL.—For applicable 

6 ESRD ambulance services furnished on or 

7 after January 1, 2017, by an applicable 

8 ambulance provider, the Secretary shall es9 tablish and implement a process under 

10 which the Secretary shall determine, in ad11 vance of furnishing such a service to an in12 dividual, whether payment for such service 

13 may not be made because such service is 

14 not covered or because of the application of 

15 section 1862(a)(1). 

16 ‘‘(ii) DENIAL OF PAYMENT.—Subject 

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

18 shall be made under this part for the serv19 ice unless the Secretary determines pursu20 ant to such process that the service meets 

21 the applicable requirements for coverage. 

22 ‘‘(B) ELEMENTS OF PROCESS.—The proc23 ess described in subparagraph (A) shall include 

24 the following elements: 


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1 ‘‘(i) In order to obtain a prior author2 ization, the applicable ambulance provider 

3 shall submit— 

4 ‘‘(I) a valid physician certifi5 cation statement (PCS) for non-emer6 gency ambulance transport; and 

7 ‘‘(II) any other documentation 

8 determined appropriate by the Sec9 retary. 

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

11 a prior authorization request within 7 busi12 ness days of receiving the request. 

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

14 a prior authorization determination within 

15 7 business days of the date of the Sec16 retary’s receipt of medical documentation 

17 needed to make such determination, sub18 paragraph (A)(ii) shall not apply. 

19 ‘‘(iii) In making the determination 

20 under subparagraph (A) with respect to a 

21 service and individual, the Secretary shall 

22 evaluate the medical necessity of the serv23 ice by determining— 

24 ‘‘(I) whether the individual is un25 able to get up from bed without asVerDate Sep 11 2014 04:32 Feb 12, 2015 Jkt 049200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S377.IS S377

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1 sistance, unable to ambulate, and un2 able to sit in a chair or wheelchair; 

3 ‘‘(II) whether the individual has 

4 a medical condition that, regardless of 

5 bed confinement, is such that trans6 port by ambulance is medically nec7 essary; or 

8 ‘‘(III) whether the individual 

9 meets other criteria as determined ap10 propriate by the Secretary. 

11 ‘‘(iv) If the prior authorization re12 quest is approved, such request shall be 

13 retroactive to the date on which such re14 quest was received. 

15 ‘‘(v) An approved prior authorization 

16 shall be valid for a 60-day period. The Sec17 retary may provide for an extension of 

18 such period if the Secretary determines 

19 such an extension is appropriate. 

20 ‘‘(vi) An approved prior authorization 

21 shall be deemed to constitute medical ne22 cessity but shall not eliminate the docu23 mentation requirements necessary to sup24 port a claim for the transport. 


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1 ‘‘(vii) Other elements determined ap2 propriate by the Secretary. 

3 ‘‘(C) RELIANCE UPON CONTRACTORS.— 

4 The Secretary may rely upon contractors to im5 plement the requirements of this paragraph. 

6 The contractor’s compensation shall be limited 

7 to a demonstration that it has reduced the 

8 number of non-emergency basic life support 

9 services involving individuals with end-stage 

10 renal disease for renal dialysis services (as de11 scribed in section 1881(b)(14)(B)) furnished 

12 other than on an emergency basis. 

13 ‘‘(D) APPLICABLE ESRD AMBULANCE

14 SERVICES.—In this paragraph, the term ‘appli15 cable ESRD ambulance services’ means ambu16 lance services consisting of non-emergency basic 

17 life support services involving transport of an 

18 individual with end-stage renal disease for renal 

19 dialysis services (as described in section 

20 1881(b)(14)(B)) furnished other than on an 

21 emergency basis. 

22 ‘‘(E) AMBULANCE PROVIDER; APPLICABLE

23 AMBULANCE PROVIDER DEFINED.—In this 

24 paragraph: 


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1 ‘‘(i) AMBULANCE PROVIDER.—The 

2 term ‘ambulance provider’ means a pro3 vider of services (as defined in section 

4 1861(u)) or other entity that furnishes am5 bulance services under this title. 

6 ‘‘(ii) APPLICABLE AMBULANCE PRO7 VIDER.—The term ‘applicable ambulance 

8 provider’ means an ambulance provider 

9 (other than an ambulance provider who is 

10 a provider of services (as defined in such 

11 section)). 

12 ‘‘(F) IMPLEMENTATION.— 

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

14 (ii), the Secretary may carry out this para15 graph through program instruction or oth16 erwise. 

17 ‘‘(ii) SUFFICIENT NOTICE TO PRE18 PARE.—Not later than June 30, 2016, the 

19 Secretary shall make the aspects of the 

20 process under this paragraph available to 

21 the public.’’. 

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

23 the Social Security Act (42 U.S.C. 1395m(l)) is amend24 ed— 


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

2 provider or under arrangement with a provider’’ and 

3 inserting ‘‘an ambulance provider (as defined in 

4 paragraph (18)(E)(i)) or under arrangement with an 

5 ambulance provider’’; 

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

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

8 of ambulance services’’ and inserting ‘‘ambulance 

9 provider (as defined in paragraph (18)(E)(i))’’; 

10 (3) in paragraph (9), in the heading, by insert11 ing ‘‘AMBULANCE’’ after ‘‘RURAL’’; 

12 (4) in paragraph (12), in the heading, by in13 serting ‘‘AMBULANCE’’ after ‘‘RURAL’’; and 

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

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

16 ‘‘ambulance provider (as defined in paragraph 

17 (18)(E)(i))’’. 

18 SEC. 4. REQUIRING AMBULANCE PROVIDERS TO SUBMIT 

19 COST AND OTHER INFORMATION. 

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

21 1395m(l)), as amended by section 3, is amended by adding 

22 at the end the following new paragraph: 

23 ‘‘(19) SUBMISSION OF COST AND OTHER INFOR24 MATION.— 


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1 ‘‘(A) DEVELOPMENT OF DATA COLLECTION

2 SYSTEM.—The Secretary shall develop a data 

3 collection system (which may include use of a 

4 cost survey and standardized definitions) for 

5 ambulance providers to collect cost, revenue, 

6 utilization, and other information determined 

7 appropriate by the Secretary. Such system shall 

8 be designed to submit information— 

9 ‘‘(i) needed to evaluate the appro10 priateness of payment rates under this 

11 subsection; 

12 ‘‘(ii) on the utilization of capital 

13 equipment and ambulance capacity; and 

14 ‘‘(iii) on different types of ambulance 

15 services furnished in different geographic 

16 locations, including rural areas and low 

17 population density areas described in para18 graph (12). 

19 ‘‘(B) SPECIFICATION OF DATA COLLEC20 TION SYSTEM.— 

21 ‘‘(i) IN GENERAL.—Not later than 

22 July 1, 2016, the Secretary shall— 

23 ‘‘(I) specify the data collection 

24 system under subparagraph (A) and 


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1 the time period during which such 

2 data is required to be submitted; and 

3 ‘‘(II) identify the ambulance pro4 viders who would be required to sub5 mit the information under such data 

6 collection system. 

7 ‘‘(ii) RESPONDENTS.—Subject to sub8 paragraph (D)(ii), the Secretary shall de9 termine an appropriate sample of ambu10 lance providers to submit information 

11 under the data collection system for each 

12 period for which reporting of data is re13 quired. 

14 ‘‘(C) PENALTY FOR FAILURE TO REPORT

15 COST AND OTHER INFORMATION.—Beginning 

16 on July 1, 2017, a 5-percent reduction to pay17 ments under this part shall be made for a 1- 

18 year prospective period specified by the Sec19 retary to an ambulance provider who— 

20 ‘‘(i) is identified under subparagraph 

21 (B)(i)(II) or (D)(ii) as being required to 

22 submit the information under the data col23 lection system; and 


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1 ‘‘(ii) does not submit such information 

2 during the period specified under subpara3 graph (B)(i)(I). 

4 ‘‘(D) ONGOING DATA COLLECTION.— 

5 ‘‘(i) REVISION OF DATA COLLECTION

6 SYSTEM.—The Secretary may, as deter7 mined appropriate, periodically revise the 

8 data collection system. 

9 ‘‘(ii) SUBSEQUENT DATA COLLEC10 TION.— 

11 ‘‘(I) IN GENERAL.—In order to 

12 continue to evaluate the appropriate13 ness of payment rates under this sub14 section, the Secretary shall, for years 

15 after 2017 (but not less often than 

16 once every 3 years), require ambu17 lance providers to submit information 

18 for a period the Secretary determines 

19 appropriate. The penalty described in 

20 subparagraph (C) shall apply to such 

21 subsequent data collection periods. 

22 ‘‘(II) SAMPLE.—For each period 

23 described in subclause (I), the Sec24 retary shall determine an appropriate 

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1 mit information under the data collec2 tion system for such period. In deter3 mining which ambulance providers 

4 would be required to submit informa5 tion for such period, the Secretary 

6 may not require an ambulance pro7 vider who has already submitted infor8 mation for a previous period to submit 

9 information for a subsequent period 

10 unless all of the ambulance providers 

11 who the Secretary determines are the 

12 same type as such ambulance provider 

13 have either submitted information or 

14 been penalized under subparagraph 

15 (C) for not doing so. 

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

17 consult with stakeholders in carrying out the 

18 development of the system and collection of in19 formation under this paragraph, including the 

20 activities described in subparagraphs (A) and 

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

22 requests for information and other mechanisms 

23 determined appropriate by the Secretary. 

24 ‘‘(F) DEFINITION OF AMBULANCE PRO25 VIDER.—In this paragraph, the term ‘ambuVerDate Sep 11 2014 04:32 Feb 12, 2015 Jkt 049200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\S377.IS S377

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1 lance provider’ has the meaning given such 

2 term in paragraph (18)(E)(i). 

3 ‘‘(G) ADMINISTRATION.—Chapter 35 of 

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

5 the collection of information required under this 

6 subsection. 

7 ‘‘(H) LIMITATIONS ON REVIEW.—There 

8 shall be no administrative or judicial review 

9 under section 1869, section 1878, or otherwise 

10 of the data collection system or identification of 

11 respondents under this paragraph. 

12 ‘‘(I) FUNDING FOR IMPLEMENTATION.— 

13 For purposes of carrying out subparagraph (A), 

14 the Secretary shall provide for the transfer, 

15 from the Federal Supplementary Medical Insur16 ance Trust Fund under section 1841, of 

17 $1,000,000 to the Centers for Medicare & Med18 icaid Services Program Management Account 

19 for fiscal year 2016. Amounts transferred under 

20 this subparagraph shall remain available until 

21 expended.’’. 

Æ 


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