I 
116TH CONGRESS 
1ST SESSION H. R. 4938 
To amend title XVIII to strengthen ambulance services furnished under 
part B of the Medicare program. 
IN THE HOUSE OF REPRESENTATIVES 
OCTOBER 31, 2019 
Ms. SEWELL of Alabama (for herself, Mr. NUNES, Mr. WELCH, Mr. MULLIN, 
and Mr. BLUMENAUER) introduced the following bill; which was referred 
to the Committee on Energy and Commerce, and in addition to the Com-
mittee 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 to strengthen ambulance services 
furnished under part B of the Medicare 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; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Medicare Ambulance Access, Fraud Prevention, and Re-
form Act of 2019’’. 
(b) TABLE OF CONTENTS.—The table of contents for 
this Act is as follows: 
VerDate Sep 11 2014 
19:03 Nov 09, 2019
Jkt 099200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H4938.IH
H4938
pamtmann on DSKBC07HB2PROD with BILLS
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 sched-
uled 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. 
TITLE I—PROTECT ACCESS TO 
HIGH QUALITY AMBULANCE 
CARE 
SEC. 101. 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 
at the end the following new paragraph: 
‘‘(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 applica-
ble to such services shall be increased by— 
‘‘(A) with respect to ground ambulance 
services for which the transportation originates 
VerDate Sep 11 2014 
19:03 Nov 09, 2019
Jkt 099200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6201
E:\BILLS\H4938.IH
H4938
pamtmann on DSKBC07HB2PROD with BILLS
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 para-
graph, 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; 
VerDate Sep 11 2014 
19:03 Nov 09, 2019
Jkt 099200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\H4938.IH
H4938
pamtmann on DSKBC07HB2PROD with BILLS
‘‘(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 para-
graph, 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 sec-
tion 1834(l) of the Social Security Act (42 U.S.C. 
1395m(l)), as adjusted under paragraph (18) 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 (17) of such section. 
(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 
VerDate Sep 11 2014 
19:03 Nov 09, 2019
Jkt 099200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H4938.IH
H4938
pamtmann on DSKBC07HB2PROD with BILLS
under paragraph (1), together with recommenda-
tions for such legislation and administrative action 
as the Secretary determines appropriate. 
SEC. 102. NATIONAL EXPANSION OF PRIOR AUTHORIZA-
TION 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)) is amended— 
(1) by redesignating subparagraphs (B) and 
(C) as subparagraphs (C) and (D), respectively; and 
(2) by inserting after subparagraph (A) the fol-
lowing 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 Reauthoriza-
tion Act of 2015, by January 1, 2020, the 
Secretary shall expand the prior authoriza-
tion model to all States using notice and 
comment rulemaking, regardless of wheth-
er or not the expansion meets the require-
ments described in paragraphs (1) through 
(3) of section 1115A(c). 
VerDate Sep 11 2014 
19:03 Nov 09, 2019
Jkt 099200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H4938.IH
H4938
pamtmann on DSKBC07HB2PROD with BILLS
‘‘(ii) If the Secretary expands the 
model of prior authorization under this 
subparagraph— 
‘‘(I) the prior authorization shall 
be limited to ambulance services con-
sisting of non-emergency basic life 
support services involving transport of 
an individual with end-stage renal dis-
ease for renal dialysis services (as de-
scribed in section 1881(b)(14)(B)) 
furnished other than on an emergency 
basis; and 
‘‘(II) in making the prior author-
ization 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 am-
bulate, and unable to sit in a 
chair or wheelchair; 
‘‘(bb) whether the individual 
has a medical condition that, re-
gardless of bed confinement, is 
VerDate Sep 11 2014 
19:03 Nov 09, 2019
Jkt 099200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H4938.IH
H4938
pamtmann on DSKBC07HB2PROD with BILLS
such that transport by ambulance 
is medically necessary; or 
‘‘(cc) whether the individual 
meets other criteria as deter-
mined appropriate by the Sec-
retary.’’. 
TITLE II—REDUCE ADMINISTRA-
TIVE BURDENS TO EXPAND 
PATIENT CARE 
SEC. 201. ELIMINATION OF DUPLICATIVE PAPERWORK RE-
QUIREMENTS IN THE MEDICARE AMBULANCE 
BENEFIT. 
Section 1834(l) of the Social Security Act (42 U.S.C. 
1395m(l)), as amended by section 101, is further amended 
by adding the following new paragraph: 
‘‘(20) REDUCING ADMINISTRATIVE BURDEN.— 
No later than July 1, 2020— 
‘‘(A) The Secretary shall through notice 
and comment rulemaking eliminate the fol-
lowing requirements to reduce the burden on 
ambulance services providers and suppliers: 
‘‘(i) The vehicle section and the 
‘extra’ practice locations for emergency 
medical services section of the 855B Am-
bulance Enrollment Form required under 
VerDate Sep 11 2014 
19:03 Nov 09, 2019
Jkt 099200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H4938.IH
H4938
pamtmann on DSKBC07HB2PROD with BILLS
section 424.505 of title 42, Code of Fed-
eral Regulations (or successor regulations). 
‘‘(ii) The requirement that individuals 
sign ambulance service claims under sec-
tion 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 Sec-
retary shall through notice and comment rule-
making— 
‘‘(i) require ambulance providers and 
suppliers to update the 855B Ambulance 
Enrollment Form required under section 
424.505 of title 42, Code of Federal Regu-
lations (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 be-
fore revoking billing authority for ambu-
lance providers and suppliers under section 
424.535 of title 42, Code of Federal Regu-
lations (or successor regulations).’’. 
VerDate Sep 11 2014 
19:03 Nov 09, 2019
Jkt 099200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H4938.IH
H4938
pamtmann on DSKBC07HB2PROD with BILLS
TITLE 
III—LEVERAGE 
AMBU-
LANCE 
SERVICES 
TO 
PRO-
TECT ACCESS TO CARE IN 
RURAL AMERICA 
SEC. 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)) is amended by adding at the end 
the following new subparagraphs: 
‘‘(C) EXCEPTION FOR RURAL AND QUALI-
FIED 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 proc-
ess 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 Sec-
VerDate Sep 11 2014 
19:03 Nov 09, 2019
Jkt 099200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H4938.IH
H4938
pamtmann on DSKBC07HB2PROD with BILLS
retary finalizes a change in the designation 
made under this paragraph.’’. 
Æ 
VerDate Sep 11 2014 
19:03 Nov 09, 2019
Jkt 099200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6301
E:\BILLS\H4938.IH
H4938
pamtmann on DSKBC07HB2PROD with BILLS