I 113th CONGRESS 2d Session H. R. 5460 IN THE HOUSE OF REPRESENTATIVES September 11, 2014 Mr. Walden (for himself, Mr. Welch , Mr. Nunes , and Mr. Neal ) introduced 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 program and to reform payments for such services under such program.

1. Short title (a) Short title This Act may be cited as the Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2014 . (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. 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: (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 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. (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 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 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 (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 recommendations for such legislation and administrative action as the Secretary determines appropriate. 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: (18) 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, 2016, by an ambulance 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 ambulance 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 provider In this paragraph, the term ambulance provider means a provider of services (as defined in section 1861(u)) or other entity that furnishes ambulance services under this title. (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, 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 amended— (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 of ambulance services and inserting ambulance provider (as defined in paragraph (18)(E)) ; (3) in paragraph (9), in the heading, by inserting ambulance after rural ; (4) in paragraph (12), in the heading, by inserting 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)) . 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 information (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 information determined appropriate by the Secretary. Such system shall be designed to submit 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). (B) Specification of data collection 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 information under such data collection system. (ii) Respondents Subject to subparagraph (D)(ii), the Secretary shall determine an appropriate sample of providers and suppliers of ambulance services to submit 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 payments under this part shall be made for a 1-year prospective period specified by the Secretary 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 system; and (ii) does not submit such information during the period specified under subparagraph (B)(i)(I). (D) Ongoing data collection (i) Revision of data collection system The Secretary may, as determined appropriate, periodically revise the data collection system. (ii) Subsequent data collection 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 submit information for a period the Secretary determines appropriate. The penalty described 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 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 subsection. (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 Insurance Trust Fund under section 1841, of $1,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for fiscal year 2015. Amounts transferred under this subparagraph shall remain available until expended. .