Title: Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2017
Policy area: Health

Summary:
Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2017
This bill increases payment under Medicare for certain ambulance services and otherwise revises provisions related to coverage of such services.

[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[S. 967 Introduced in Senate (IS)]

<DOC>






115th CONGRESS
  1st Session
                                 S. 967

 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

                             April 27, 2017

Ms. Stabenow (for herself, Mr. Roberts, Mr. Leahy, Ms. Collins, and Mr. 
   Schumer) 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 2017''.
    (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 providers of services and ambulance service providers 
                            to submit cost data and other information 
                            with respect to ambulance services.
Sec. 5. Treatment of ambulance service providers.

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:
            ``(17) Increase in conversion factor for ground ambulance 
        services.--In the case of ground ambulance services furnished 
        on or after January 1, 2018, 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.
            ``(18) Increase in mileage rate for ground ambulance 
        services.--In the case of ground ambulance services furnished 
        on or after January 1, 2018, 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 (17) 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 (20) of such section, as 
        added by section 4.
            (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.

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:
            ``(19) 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, 2019, by a provider of services or 
                        an ambulance service 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 provider of services or 
                        ambulance service 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 service provider.--In this 
                paragraph, the term `ambulance service provider' means 
                an entity that furnishes ambulance services (as 
                described in section 1861(s)(7)) and is not a provider 
                of services (as defined section 1861(u)).
                    ``(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, 2018, the Secretary shall 
                        make the aspects of the process under this 
                        paragraph available to the public.''.
    (b) References to Ambulance Service Providers.--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'' and inserting ``an ambulance service provider (as 
        defined in paragraph (19)(E)) or under arrangement with an 
        ambulance service provider or by a provider'';
            (2) in paragraph (8), in the matter following subparagraph 
        (B), by striking ``supplier of ambulance services'' and 
        inserting ``ambulance service provider (as defined in paragraph 
        (19)(E))'';
            (3) in paragraph (9), in the heading, by inserting 
        ``providers of services and ambulance service'' after 
        ``rural'';
            (4) in paragraph (12), in the heading, by inserting 
        ``providers of services and ambulance service'' after 
        ``rural''; and
            (5) in each of subparagraphs (B)(ii) and (D)(ii) of 
        paragraph (14), by striking ``entity'' and inserting ``provider 
        of services or ambulance service provider (as defined in 
        paragraph (19)(E))''.

SEC. 4. REQUIRING PROVIDERS OF SERVICES AND AMBULANCE SERVICE PROVIDERS 
              TO SUBMIT COST DATA AND OTHER INFORMATION WITH RESPECT TO 
              AMBULANCE SERVICES.

    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:
            ``(20) Submission of cost data and other information.--
                    ``(A) Development of data collection system.--
                            ``(i) In general.--The Secretary shall 
                        develop a data collection system for the 
                        submission by providers of services and 
                        ambulance service providers (as defined in 
                        paragraph (19)(E)) of data on cost, revenue, 
                        and utilization with respect to ambulance 
                        services, and other information determined 
                        appropriate by the Secretary. Such system shall 
                        enable providers of services and ambulance 
                        service providers to submit to the Secretary 
                        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).
                            ``(ii) Collection of cost data 
                        information.--For purposes of collecting the 
                        cost data information described in subparagraph 
                        (B)(iv), the Secretary shall use the sampling 
                        methodology described in subparagraph (B)(ii).
                    ``(B) Specification of data collection system.--
                            ``(i) In general.--Not later than 90 days 
                        after the date of enactment of this paragraph, 
                        the Secretary shall specify the data collection 
                        system developed under subparagraph (A), which 
                        shall consist of the basic data collection 
                        described in clause (iii) and the cost data 
                        information described in clause (iv), and the 
                        time period for which the reporting of such 
                        data is required under this paragraph.
                            ``(ii) Selection of providers of services 
                        and ambulance service providers required to 
                        submit cost data information.--
                                    ``(I) In general.--Subject to 
                                subparagraph (D)(ii), the Secretary 
                                shall determine a statistically 
                                appropriate sample of providers of 
                                services and ambulance service 
                                providers based upon the organizational 
                                designation of the provider of services 
                                or ambulance service provider as 
                                described in clause (iii)(I) to submit 
                                cost data information under clause (iv) 
                                for each period for which the reporting 
                                of such data is required, as specified 
                                under clause (i).
                                    ``(II) Implementation.--In 
                                determining an appropriate sample of 
                                providers of services and ambulance 
                                service providers under subclause (I), 
                                the Secretary shall promulgate an 
                                interim final rule and shall accept and 
                                consider public comments on the interim 
                                final rule for 30 days after the date 
                                of publication of such interim final 
                                rule.
                                    ``(III) Notification of providers 
                                of services and ambulance service 
                                providers selected.--Not later than 180 
                                days after the date on which the 
                                Secretary has completed the basic data 
                                collection under clause (iii), the 
                                Secretary shall provide notice to those 
                                providers of services and ambulance 
                                service providers selected under this 
                                clause to submit cost data information 
                                under clause (iv).
                            ``(iii) Basic data collection.--The 
                        Secretary shall require providers of services 
                        and ambulance service providers to submit 
                        information under the data collection system 
                        under this paragraph, such as the following 
                        with respect to the provider of services or 
                        ambulance service provider, not later than the 
                        date that is 120 days after the date on which 
                        the Secretary specifies such data collection 
                        system under clause (i), and not less often 
                        than once every 5 years thereafter:
                                    ``(I) The organizational 
                                designation of the provider of services 
                                or ambulance service provider as a 
                                government ambulance authority, 
                                independent ambulance company, public 
                                safety or fire department-based 
                                organization, hospital-based 
                                organization, or other type of 
                                organization.
                                    ``(II) The percentage of volunteer 
                                emergency medical technician labor the 
                                provider of services or ambulance 
                                service provider relies on.
                                    ``(III) The volume of ambulance 
                                services furnished per year.
                                    ``(IV) The percentage of emergency 
                                and non-emergency services furnished 
                                under this title per year.
                                    ``(V) The average duration of 
                                transports.
                                    ``(VI) Whether the provider of 
                                services or ambulance service provider 
                                has a sole source contract and the 
                                percentage of the activity provided 
                                under that contract.
                                    ``(VII) Whether the provider of 
                                services or ambulance service provider 
                                is required to pay fees to the local 
                                jurisdiction to subsidize emergency and 
                                other services as a requirement of 
                                doing business.
                                    ``(VIII) The percentage of 
                                transports that are urban, rural, or in 
                                a low-population density area described 
                                in paragraph (12), as determined by the 
                                Secretary.
                                    ``(IX) Other data elements that the 
                                Secretary, in consultation with 
                                stakeholders, determines appropriate.
                            ``(iv) Cost data information.--The 
                        Secretary shall require those providers of 
                        services and ambulance service providers 
                        selected under clause (ii) to submit under the 
                        data collection system under this paragraph for 
                        each period for which the reporting of such 
                        data is required, as specified under clause 
                        (i), data on cost, revenue, and utilization, 
                        such as--
                                    ``(I) data on total revenue, 
                                including revenues under this title, 
                                subscription programs, Medicaid, other 
                                health care plans and self-pay, public 
                                funding, fundraising and donations, 
                                uncompensated care, and write-offs; and
                                    ``(II) data on total cost including 
                                labor costs (paid and volunteer), 
                                operating costs, administrative costs, 
                                vehicle and fleet costs, communications 
                                costs, equipment and supplies 
                                (including drugs), maintenance, 
                                building and facility costs, 
                                administrative costs, local 
                                jurisdiction costs, the cost of 
                                readiness, and central office 
                                administration costs.
                    ``(C) Penalty for failure to report cost data 
                information.--
                            ``(i) In general.--Beginning on January 1, 
                        2021, subject to clause (ii), a 5-percent 
                        reduction to payments under this part shall be 
                        made for a 1-year prospective period specified 
                        by the Secretary to a provider of services or 
                        ambulance service provider who--
                                    ``(I) is identified under 
                                subparagraph (B)(ii) or (D)(ii) as 
                                being required to submit information 
                                under subparagraph (B)(iv) or (D)(ii), 
                                respectively; and
                                    ``(II) does not submit such 
                                information in a timely manner for the 
                                period specified under subparagraph 
                                (B)(i) or (D)(ii), respectively.
                            ``(ii) Exception.--The Secretary may 
                        suspend the payment reduction under clause (i) 
                        with respect to a period in the event of a 
                        natural disaster, bankruptcy, or other similar 
                        situation that the Secretary determines 
                        interfered with ability of the provider of 
                        services or ambulance service provider to 
                        submit such information in a timely manner for 
                        the specified period.
                    ``(D) Ongoing cost data collection.--
                            ``(i) Revision of data collection system.--
                        The Secretary may, as appropriate, periodically 
                        revise the data collection system under this 
                        paragraph.
                            ``(ii) Subsequent cost 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 2020 (but not more 
                                frequently than once every 3 years), 
                                require providers of services and 
                                ambulance service providers to submit 
                                information described in subparagraph 
                                (B)(iv) for a period the Secretary 
                                determines appropriate. The penalty 
                                described in subparagraph (C) shall 
                                apply to each such subsequent data 
                                collection period in accordance with 
                                such subparagraph.
                                    ``(II) Sample.--For each period 
                                described in subclause (I), the 
                                Secretary shall determine a 
                                statistically appropriate sample of 
                                providers of services and ambulance 
                                services providers to submit 
                                information under the data collection 
                                system for the period. In determining 
                                which providers of services and 
                                ambulance service providers would be 
                                required to submit information for such 
                                period, the Secretary may not require a 
                                provider of services or ambulance 
                                service provider who has already 
                                submitted information for a previous 
                                period to submit information for a 
                                subsequent period unless all of the 
                                providers of services and ambulance 
                                service providers that the Secretary 
                                determines are of the same type as such 
                                provider of services or ambulance 
                                service provider have either submitted 
                                information or been penalized under 
                                subparagraph (C) for failing to do so 
                                in a timely manner.
                    ``(E) Consultation.--The Secretary shall consult 
                with stakeholders in carrying out the development of 
                the data collection system and the 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) Administration.--Chapter 35 of title 44, 
                United States Code, shall not apply to the collection 
                of information required under this paragraph.
                    ``(G) Limitations on review.--There shall be no 
                administrative or judicial review under section 1869, 
                section 1878, or otherwise of the data collection 
                system under this paragraph, the determination of 
                providers of services and ambulance service providers 
                required to submit information under the data 
                collection system, or the application of the penalty 
                for failure to report information under subparagraph 
                (C).
                    ``(H) 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.''.

SEC. 5. TREATMENT OF AMBULANCE SERVICE PROVIDERS.

    (a) In General.--Section 1834 of the Social Security Act (42 U.S.C. 
1395m(l)), as amended by section 4, is amended by adding at the end the 
following new paragraph:
            ``(21) Treatment of ambulance service providers as 
        providers of services for certain purposes.--
                    ``(A) Provider reimbursement review board.--For 
                purposes of section 1878, an ambulance service provider 
                (as defined in paragraph (19)(E)) shall be treated as a 
                provider of services.
                    ``(B) Establishment of conditions of 
                participation.--An ambulance service provider--
                            ``(i) for purposes of section 1865(a)(1), 
                        shall be treated as a provider entity; and
                            ``(ii) shall be required to meet such 
                        requirements for participation under this title 
                        as the Secretary shall establish by regulation.
                    ``(C) Use of billing codes.--An ambulance service 
                provider may, for purposes of this title, use billing 
                codes established for providers of services, if such 
                use is consistent with applicable Federal, State, or 
                local scope of practice requirements.''.
    (b) Effective Date.--The amendment made this section shall take 
effect on January 1, 2018, and shall apply to an ambulance service 
provider on or after such date.
                                 <all>