Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2019

To amend title XVIII to strengthen ambulance services furnished under part B of the Medicare program. 1. Short title; table of contents (a) Short title This Act may be cited as the Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2019 (b) Table of contents The table of contents for this Act is as follows: Sec. 1. Short title; table of contents. Title I—Protect Access to High Quality Ambulance Care Sec. 101. Reform to the Medicare ambulance fee schedule. Sec. 102. National expansion of prior authorization model for repetitive scheduled non-emergent ambulance transport. Title II—Reduce Administrative Burdens To Expand Patient Care Sec. 201. Elimination of duplicative paperwork requirements in the Medicare ambulance benefit. Title III—Leverage Ambulance Services To Protect Access to Care in Rural America Sec. 301. Protecting access to ambulance services in rural and low population density areas. I Protect Access to High Quality Ambulance Care 101. Reform to the Medicare ambulance fee schedule (a) In general Section 1834(l) of the Social Security Act ( 42 U.S.C. 1395m(l) (18) Increase in conversion factor for ground ambulance services In the case of ground ambulance services furnished on or after January 1, 2020, 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. (19) Increase in mileage rate for ground ambulance services In the case of ground ambulance services furnished on or after January 1, 2020, 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) (2) Report Not later than January 1, 2022, 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. 102. National expansion of prior authorization model for repetitive scheduled non-emergent ambulance transport (a) In general Section 1834(l)(16) of the Social Security Act ( 42 U.S.C. 1395m(l)(16) (1) by redesignating subparagraphs (B) and (C) as subparagraphs (C) and (D), respectively; and (2) by inserting after subparagraph (A) the following new subparagraph: (B) Permanent expansion (i) If by July 1, 2019, the Secretary has not already expanded to all States the model of prior authorization described in paragraph (2) of section 515(a) of the Medicare Access and CHIP Reauthorization Act of 2015, by January 1, 2020, the Secretary shall expand the prior authorization model to all States using notice and comment rulemaking, regardless of whether or not the expansion meets the requirements described in paragraphs (1) through (3) of section 1115A(c). (ii) If the Secretary expands the model of prior authorization under this subparagraph— (I) the prior authorization shall be limited to 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; and (II) in making the prior authorization determination with respect to a service and individual, the Secretary shall evaluate the medical necessity of the service by determining— (aa) whether the individual is unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair; (bb) whether the individual has a medical condition that, regardless of bed confinement, is such that transport by ambulance is medically necessary; or (cc) whether the individual meets other criteria as determined appropriate by the Secretary. . II Reduce Administrative Burdens To Expand Patient Care 201. Elimination of duplicative paperwork requirements in the Medicare ambulance benefit Section 1834(l) of the Social Security Act ( 42 U.S.C. 1395m(l) (20) Reducing administrative burden No later than July 1, 2020— (A) The Secretary shall through notice and comment rulemaking eliminate the following requirements to reduce the burden on ambulance services providers and suppliers: (i) The vehicle section and the extra (ii) The requirement that individuals sign ambulance service claims under section 424.36 of title 42, Code of Federal Regulations (or successor regulations), when other documentation establishing that the individual received the ambulance services is available. (B) Not later than July 1, 2020, the Secretary shall through notice and comment rulemaking— (i) require ambulance providers and suppliers to update the 855B Ambulance Enrollment Form required under section 424.505 of title 42, Code of Federal Regulations (or successor regulations), no more than once a calendar year; and (ii) establish a process to take into account inaccuracies in Social Security records or other official death records before revoking billing authority for ambulance providers and suppliers under section 424.535 of title 42, Code of Federal Regulations (or successor regulations). . III Leverage Ambulance Services To Protect Access to Care in Rural America 301. Protecting access to ambulance services in rural and low population density areas Section 1834(l)(12) of the Social Security Act ( 42 U.S.C. 1395m(l)(12) (C) Exception for Rural and Qualified Rural Areas The Secretary shall deem an area designated as a rural or qualified rural area under this paragraph that would otherwise no longer receive such designation to retain its previous designated status if there are 1,000 or fewer individuals per square mile in the area. (D) Right to Appeal Rural Areas and Qualified Rural Areas The Secretary shall establish an administrative appeals process to allow ambulance services providers and suppliers to seek reconsideration of a change in a ZIP code’s status as a rural or qualified rural area during the first 12 months after the Secretary finalizes a change in the designation made under this paragraph. .

Summary: Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2019 This bill establishes a series of requirements relating to coverage of ground ambulance services under Medicare. Specifically, the Centers for Medicare & Medicaid Services (CMS) must continue to designate an area as a rural or qualified rural area that is eligible for increased payment under Medicare, even if the area would otherwise no longer qualify for such designation, if the area has a specified population density. The CMS must also establish an administrative process to allow ambulance service providers to appeal a change in an area's designation. The bill also requires the CMS to (1) expand to all states a prior authorization model for repetitive scheduled nonemergent ambulance transport, in accordance with specified limitations, if such an expansion has not already occurred by a certain date; (2) increase payment rates for ground ambulance services; and (3) eliminate certain administrative requirements for such services.