I 
113TH CONGRESS 
2D SESSION 
H. R. 5460 
To amend title XVIII of the Social Security Act to increase access to ambu-
lance 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) intro-
duced 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 pro-
gram and to reform payments for such services under 
such program. 
Be it enacted by the Senate and House of Representa-
tives 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 Re-
form Act of 2014’’. 
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(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 Se-
curity 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 sub-
section, 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 
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a rural census tract described in such para-
graph, 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 sub-
section, the payment rate for mileage otherwise ap-
plicable 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 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.’’. 
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(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 sec-
tion 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, 2019, 
the Secretary of Health and Human Services shall 
submit to Congress a report on the study conducted 
under paragraph (1), together with recommenda-
tions for such legislation and administrative action 
as the Secretary determines appropriate. 
SEC. 3. PRIOR AUTHORIZATION FOR AMBULANCE TRANS-
PORTS OF ESRD BENEFICIARIES. 
(a) IN GENERAL.—Section 1834(l) of the Social Se-
curity Act (42 U.S.C. 1395m(l)), as amended by section 
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2, is amended by adding at the end the following new 
paragraph: 
‘‘(18) PRIOR
AUTHORIZATION
OF
COVERAGE 
FOR
AMBULANCE
TRANSPORTS
OF
ESRD
BENE-
FICIARIES.— 
‘‘(A) PROCESS.— 
‘‘(i) IN
GENERAL.—For applicable 
ESRD ambulance services furnished on or 
after January 1, 2016, by an ambulance 
provider, the Secretary shall establish and 
implement a process under which the Sec-
retary shall determine, in advance of fur-
nishing such a service to an individual, 
whether payment for such service may not 
be made because such service is not cov-
ered or because of the application of sec-
tion 1862(a)(1). 
‘‘(ii) DENIAL OF PAYMENT.—Subject 
to subparagraph (B)(ii)(II), no payment 
shall be made under this part for the serv-
ice unless the Secretary determines pursu-
ant to such process that the service meets 
the applicable requirements for coverage. 
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‘‘(B) ELEMENTS OF PROCESS.—The proc-
ess described in subparagraph (A) shall include 
the following elements: 
‘‘(i) In order to obtain a prior author-
ization, the ambulance provider shall sub-
mit— 
‘‘(I) a valid physician certifi-
cation statement (PCS) for non-emer-
gency ambulance transport; and 
‘‘(II) any other documentation 
determined appropriate by the Sec-
retary. 
‘‘(ii)(I) The Secretary shall respond to 
a prior authorization request within 7 busi-
ness 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 Sec-
retary’s receipt of medical documentation 
needed to make such determination, sub-
paragraph (A)(ii) shall not apply. 
‘‘(iii) In making the determination 
under subparagraph (A) with respect to a 
service and individual, the Secretary shall 
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evaluate the medical necessity of the serv-
ice by determining— 
‘‘(I) whether the individual is un-
able to get up from bed without as-
sistance, unable to ambulate, and un-
able to sit in a chair or wheelchair; 
‘‘(II) whether the individual has 
a medical condition that, regardless of 
bed confinement, is such that trans-
port by ambulance is medically nec-
essary; or 
‘‘(III) whether the individual 
meets other criteria as determined ap-
propriate by the Secretary. 
‘‘(iv) If the prior authorization re-
quest is approved, such request shall be 
retroactive to the date on which such re-
quest was received. 
‘‘(v) An approved prior authorization 
shall be valid for a 60-day period. The Sec-
retary 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 ne-
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cessity but shall not eliminate the docu-
mentation requirements necessary to sup-
port a claim for the transport. 
‘‘(vii) Other elements determined ap-
propriate by the Secretary. 
‘‘(C) RELIANCE
UPON
CONTRACTORS.— 
The Secretary may rely upon contractors to im-
plement 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 de-
scribed in section 1881(b)(14)(B)) furnished 
other than on an emergency basis. 
‘‘(D) 
APPLICABLE
ESRD
AMBULANCE 
SERVICES.—In this paragraph, the term ‘appli-
cable ESRD ambulance services’ means ambu-
lance 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. 
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‘‘(E) AMBULANCE
PROVIDER.—In this 
paragraph, the term ‘ambulance provider’ 
means a provider of services (as defined in sec-
tion 1861(u)) or other entity that furnishes am-
bulance services under this title. 
‘‘(F) IMPLEMENTATION.— 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), the Secretary may carry out this para-
graph through program instruction or oth-
erwise. 
‘‘(ii) SUFFICIENT
NOTICE
TO
PRE-
PARE.—Not later than June 30, 2015, 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 amend-
ed— 
(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)) or under arrangement with an 
ambulance provider’’; 
(2) in paragraph (8), in the matter following 
subparagraph (B), by striking ‘‘provider or supplier 
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of ambulance services’’ and inserting ‘‘ambulance 
provider (as defined in paragraph (18)(E))’’; 
(3) in paragraph (9), in the heading, by insert-
ing ‘‘AMBULANCE’’ after ‘‘RURAL’’; 
(4) in paragraph (12), in the heading, by in-
serting ‘‘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))’’. 
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 INFOR-
MATION.— 
‘‘(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 
providers and suppliers of ambulance services to 
collect cost, revenue, utilization, and other in-
formation determined appropriate by the Sec-
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retary. Such system shall be designed to submit 
information— 
‘‘(i) needed to evaluate the appro-
priateness 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 para-
graph (12). 
‘‘(B) SPECIFICATION
OF
DATA
COLLEC-
TION SYSTEM.— 
‘‘(i) IN
GENERAL.—Not later than 
July 1, 2015, 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 providers and 
suppliers of ambulance services who 
would be required to submit the infor-
mation under such data collection sys-
tem. 
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‘‘(ii) RESPONDENTS.—Subject to sub-
paragraph (D)(ii), the Secretary shall de-
termine an appropriate sample of providers 
and suppliers of ambulance services to sub-
mit 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, 2016, a 5-percent reduction to pay-
ments under this part shall be made for a 1- 
year prospective period specified by the Sec-
retary to a provider or supplier of ambulance 
services who— 
‘‘(i) is identified under subparagraph 
(B)(i)(II) as being required to submit the 
information under the data collection sys-
tem; and 
‘‘(ii) does not submit such information 
during the period specified under subpara-
graph (B)(i)(I). 
‘‘(D) ONGOING DATA COLLECTION.— 
‘‘(i) REVISION OF DATA COLLECTION 
SYSTEM.—The Secretary may, as deter-
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mined appropriate, periodically revise the 
data collection system. 
‘‘(ii) SUBSEQUENT
DATA
COLLEC-
TION.—In order to continue to evaluate 
the appropriateness of payment rates 
under this subsection, the Secretary shall, 
for years after 2016 (but not less often 
than once every 3 years), require providers 
and suppliers of ambulance services to sub-
mit information for a period the Secretary 
determines appropriate. The penalty de-
scribed in subparagraph (C) shall apply to 
such subsequent data collection periods. 
‘‘(E) CONSULTATION.—The Secretary shall 
consult with stakeholders in carrying out the 
development of the system and collection of in-
formation 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) ADMINISTRATION.—Chapter 35 of 
title 44, United States Code, shall not apply to 
the collection of information required under this 
subsection. 
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‘‘(G) 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. 
‘‘(H) FUNDING FOR IMPLEMENTATION.— 
For purposes of carrying out subparagraph (A), 
the Secretary shall provide for the transfer, 
from the Federal Supplementary Medical Insur-
ance Trust Fund under section 1841, of 
$1,000,000 to the Centers for Medicare & Med-
icaid Services Program Management Account 
for fiscal year 2015. Amounts transferred under 
this subparagraph shall remain available until 
expended.’’. 
Æ 
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