Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2014 - Amends part B (Supplementary Medical Insurance Benefits) of title XVIII (Medicare) of the Social Security Act with respect to the ambulance fee schedule to: (1) increase the conversion factor for ground ambulance services in the formula for determining the appropriate fee, and (2) increase the mileage rate for such services.
Directs the Secretary of Health and Human Services (HHS) to study how the conversion factor should be modified, if at all, to take into account the cost of providing ambulance services in urban, rural, and super-rural areas.
Directs the Secretary to establish a process to determine, in advance of furnishing end stage renal disease (ESRD) ambulance services, whether payment for them may not be made because they are not covered or because they are excluded from coverage. Prohibits any payment unless the Secretary determines, pursuant to this process, that the service meets coverage requirements.
Directs the Secretary to develop a data collection system for providers and suppliers of ambulance services to collect cost, revenue, utilization, and other appropriate information.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5460 Introduced in House (IH)]
113th CONGRESS
2d Session
H. R. 5460
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.
_______________________________________________________________________
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.
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 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.
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:
``(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.
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:
``(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))''.
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 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.''.
<all>
Introduced in House
Introduced in House
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.
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.
Referred to the Subcommittee on Health.
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