,,ii  #aaeth ,,congress  #ast ,session  
,s4 #ifg  ,,in ,,the ,,senate ,,of ,,the
 ,,united ,,states  ,april #bg1         
#bjag,ms4 ,stabenow 7for herself1 ,mr4  
,roberts1 ,mr4 ,leahy1 ,ms4 ,collins1   
and ,mr4 ,schumer7 introduced the       
following bill2 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 program1  
and for other purposes4  #a4 ,short     
title  7a7 ,short title ,this ,act may  
be cited as the ,medicare ,ambulance    
,access1 ,fraud ,prevention1 and ,reform
 ,act of #bjag4  7b7 ,table of contents 
,the table of contents of this ,act is  
as follows3 ,sec4 #a4 ,short title4     
,sec4 #b4 ,reform to the ,medicare      
ambulance fee schedule4 ,sec4 #c4 ,prior
 authorization for ambulance transports 
of ,,esrd beneficiaries4 ,sec4 #d4      
,requiring providers of services and    

ambulance service providers to submit   
cost data and other information with    
respect to ambulance services4 ,sec4 #e4
 ,treatment of ambulance service        
providers4  #b4 ,reform to the ,medicare
 ambulance fee schedule  7a7 ,in general
 ,section #ahcd7l7 of the ,social       
,security ,act 7#db ,u4,s4,c4 #aciem7l77
 is amended by adding the following new 
paragraphs3  7#ag7 ,increase in         
conversion factor for ground ambulance  
services ,in the case of ground         
ambulance services furnished on or after
 ,january #a1 #bjah1 for purposes of    
determining the fee schedule amount for 
such services under this subsection1 the
 conversion factor otherwise applicable 
to such services shall be increased by--
  7,a7 with respect to ground ambulance 
services for which the transportation   
originates in a qualified rural area1 as
 identified using the methodology       
described in paragraph 7#ab77;,b77iii71 
#be4f percent2  7,b7 with respect to    
ground ambulance services not described 

in subparagraph 7,a7 and for which the  
transportation originates in a rural    
area described under paragraph 7#i7 or  
in a rural census tract described in    
such paragraph1 #c percent2 and  7,c7   
with respect to ground ambulance        
services not described in subparagraph  
7,a7 or 7,b71 #b percent4  7#ah7        
,increase in mileage rate for ground    
ambulance services ,in the case of      
ground ambulance services furnished on  
or after ,january #a1 #bjah1 for        
purposes of determining the fee schedule
 amount for such services under this    
subsection1 the payment rate for mileage
 otherwise applicable to such services  
shall be increased by--  7,a7 with      
respect to ground ambulance services for
 which the transportation originates in 
a qualified rural area1 as identified   
using the methodology described in      
paragraph 7#ab77;,b77iii71 #c percent2  
7,b7 with respect to ground ambulance   
services not described in subparagraph  
7,a7 and for which the transportation   

originates in a rural area described    
under paragraph 7#i7 or in a rural      
census tract described in such          
paragraph1 #c percent2 and  7,c7 with   
respect to ground ambulance services not
 described in subparagraph 7,a7 or 7,b71
 #b percent4  4  7b7 ,study and report  
7#a7 ,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 #ahcd7l7 of the ,social         
,security ,act 7#db ,u4,s4,c4           
#aciem7l771 as adjusted under paragraph 
7#ag7 of such section 7as added by      
subsection 7a771 should be modified1 if 
at all1 to take into account the cost of
 providing services in urban1 rural1 and
 super-rural areas4 ,in determining such
 costs1 the ,secretary shall use the    
data collected through the data         
collection system under paragraph 7#bj7 
of such section1 as added by section #d4
  7#b7 ,report ,not later than ,january 

#a1 #bjbb1 the ,secretary of ,health and
 ,human ,services shall submit to       
,congress a report on the study         
conducted under paragraph 7#a71 together
 with recommendations for such          
legislation and administrative action as
 the ,secretary determines appropriate4 
#c4 ,prior authorization for ambulance  
transports of ,,esrd beneficiaries  7a7 
,in general ,section #ahcd7l7 of the    
,social ,security ,act 7#db ,u4,s4,c4   
#aciem7l771 as amended by section #b1 is
 amended by adding at the end the       
following new paragraph3  7#ai7 ,prior  
authorization of coverage for ambulance 
transports of ,,esrd beneficiaries  7,a7
 ,process  7i7 ,in general ,for         
applicable ,,esrd ambulance services    
furnished on or after ,january #a1      
#bjai1 by a provider of services or an  
ambulance service provider1 the         
,secretary shall establish and implement
 a process under which the ,secretary   
shall determine1 in advance of          
furnishing such a service to an         

individual1 whether payment for such    
service may not be made because such    
service is not covered or because of the
 application of section #ahfb7;a77#a74  
7ii7 ,denial of payment ,subject to     
subparagraph 7,b77ii77,,ii71 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 coverage4  7,b7        
,elements of process ,the process       
described in subparagraph 7,a7 shall    
include the following elements3 7i7 ,in 
order to obtain a prior authorization1  
the provider of services or ambulance   
service provider shall submit--  7,i7 a 
valid physician certification statement 
7,,pcs7 for non-emergency ambulance     
transport2 and  7,,ii7 any other        
documentation determined appropriate by 
the ,secretary4  7ii7 7,i7 ,the         
,secretary shall respond to a prior     
authorization request within #g business
 days of receiving the request4  7,,ii7 

,if the ,secretary does not make a prior
 authorization determination within #g  
business days of the date of the        
,secretary's receipt of medical         
documentation needed to make such       
determination1 subparagraph 7,a77ii7    
shall not apply4  7iii7 ,in making the  
determination under subparagraph 7,a7   
with respect to a service and           
individual1 the ,secretary shall        
evaluate the medical necessity of the   
service by determining--  7,i7 whether  
the individual is unable to get up from 
bed without assistance1 unable to       
ambulate1 and unable to sit in a chair  
or wheelchair2  7,,ii7 whether the      
individual has a medical condition that1
 regardless of bed confinement1 is such 
that transport by ambulance is medically
 necessary2 or  7,,iii7 whether the     
individual meets other criteria as      
determined appropriate by the           
,secretary4  7iv7 ,if the prior         
authorization request is approved1 such 
request shall be retroactive to the date

 on which such request was received4    
7v7 ,an approved prior authorization    
shall be valid for a #fj-;day period4   
,the ,secretary may provide for an      
extension of such period if the         
,secretary determines such an extension 
is appropriate4  7vi7 ,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 transport4  7vii7 ,other  
elements determined appropriate by the  
,secretary4  7,c7 ,reliance upon        
contractors ,the ,secretary may rely    
upon contractors to implement the       
requirements of this paragraph4 ,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 7as        
described in section                    
#ahha7;b77#ad77;,b77 furnished other    

than on an emergency basis4  7,d7       
,applicable ,,esrd ambulance services   
,in this paragraph1 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 7as         
described in section                    
#ahha7;b77#ad77;,b77 furnished other    
than on an emergency basis4  7,e7       
,ambulance service provider ,in this    
paragraph1 the term ambulance service   
provider means an entity that furnishes 
ambulance services 7as described in     
section #ahfa7s77#g77 and is not a      
provider of services 7as defined section
 #ahfa7u774  7,f7 ,implementation  7i7  
,in general ,subject to clause 7ii71 the
 ,secretary may carry out this paragraph
 through program instruction or         
otherwise4  7ii7 ,sufficient notice to  
prepare ,not later than ,june #cj1      
#bjah1 the ,secretary shall make the    

aspects of the process under this       
paragraph available to the public4  4   
7b7 ,references to ambulance service    
providers ,section #ahcd7l7 of the      
,social ,security ,act 7#db ,u4,s4,c4   
#aciem7l77 is amended-- 7#a7 in         
paragraph 7#a71 by striking a supplier  
or provider and inserting an ambulance  
service provider 7as defined in         
paragraph 7#ai77;,e77 or under          
arrangement with an ambulance service   
provider or by a provider2  7#b7 in     
paragraph 7#h71 in the matter following 
subparagraph 7,b71 by striking supplier 
of ambulance services and inserting     
ambulance service provider 7as defined  
in paragraph 7#ai77;,e772  7#c7 in      
paragraph 7#i71 in the heading1 by      
inserting providers of services and     
ambulance service after rural2  7#d7 in 
paragraph 7#ab71 in the heading1 by     
inserting providers of services and     
ambulance service after rural2 and  7#e7
 in each of subparagraphs 7,b77ii7 and  
7,d77ii7 of paragraph 7#ad71 by striking

 entity and inserting provider of       
services or ambulance service provider  
7as defined in paragraph 7#ai77;,e774   
#d4 ,requiring providers of services and
 ambulance service providers to submit  
cost data and other information with    
respect to ambulance services ,section  
#ahcd7l7 of the ,social ,security ,act  
7#db ,u4,s4,c4 #aciem7l771 as amended by
 section #c1 is amended by adding at the
 end the following new paragraph3  7#bj7
 ,submission of cost data and other     
information  7,a7 ,development of data  
collection system  7i7 ,in general ,the 
,secretary shall develop a data         
collection system for the submission by 
providers of services and ambulance     
service providers 7as defined in        
paragraph 7#ai77;,e77 of data on cost1  
revenue1 and utilization with respect to
 ambulance services1 and other          
information determined appropriate by   
the ,secretary4 ,such system shall      
enable providers of services and        
ambulance service providers to submit to

 the ,secretary information--  7,i7     
needed to evaluate the appropriateness  
of payment rates under this subsection2 
7,,ii7 on the utilization of capital    
equipment and ambulance capacity2 and   
7,,iii7 on different types of ambulance 
services furnished in different         
geographic locations1 including rural   
areas and low population density areas  
described in paragraph 7#ab74  7ii7     
,collection of cost data information    
,for purposes of collecting the cost    
data information described in           
subparagraph 7,b77iv71 the ,secretary   
shall use the sampling methodology      
described in subparagraph 7,b77ii74     
7,b7 ,specification of data collection  
system  7i7 ,in general ,not later than 
#ij days after the date of enactment of 
this paragraph1 the ,secretary shall    
specify the data collection system      
developed under subparagraph 7,a71 which
 shall consist of the basic data        
collection described in clause 7iii7 and
 the cost data information described in 

clause 7iv71 and the time period for    
which the reporting of such data is     
required under this paragraph4  7ii7    
,selection of providers of services and 
ambulance service providers required to 
submit cost data information  7,i7 ,in  
general ,subject to subparagraph        
7,d77ii71 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 
7iii77,i7 to submit cost data           
information under clause 7iv7 for each  
period for which the reporting of such  
data is required1 as specified under    
clause 7i74  7,,ii7 ,implementation ,in 
determining an appropriate sample of    
providers of services and ambulance     
service providers under subclause 7,i71 
the ,secretary shall promulgate an      
interim final rule and shall accept and 
consider public comments on the interim 

final rule for #cj days after the date  
of publication of such interim final    
rule4  7,,iii7 ,notification of         
providers of services and ambulance     
service providers selected ,not later   
than #ahj days after the date on which  
the ,secretary has completed the basic  
data collection under clause 7iii71 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 7iv74  7iii7 ,basic data   
collection ,the ,secretary shall require
 providers of services and ambulance    
service providers to submit information 
under the data collection system under  
this paragraph1 such as the following   
with respect to the provider of services
 or ambulance service provider1 not     
later than the date that is #abj days   
after the date on which the ,secretary  
specifies such data collection system   
under clause 7i71 and not less often    
than once every #e years thereafter3    

7,i7 ,the organizational designation of 
the provider of services or ambulance   
service provider as a government        
ambulance authority1 independent        
ambulance company1 public safety or fire
 department-based organization1         
hospital-based organization1 or other   
type of organization4  7,,ii7 ,the      
percentage of volunteer emergency       
medical technician labor the provider of
 services or ambulance service provider 
relies on4  7,,iii7 ,the volume of      
ambulance services furnished per year4  
7,,iv7 ,the percentage of emergency and 
non-emergency services furnished under  
this title per year4  7,v7 ,the average 
duration of transports4  7,,vi7 ,whether
 the provider of services or ambulance  
service provider has a sole source      
contract and the percentage of the      
activity provided under that contract4  
7,,vii7 ,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
 business4  7,,viii7 ,the percentage of 
transports that are urban1 rural1 or in 
a low-population density area described 
in paragraph 7#ab71 as determined by the
 ,secretary4  7,,ix7 ,other data        
elements that the ,secretary1 in        
consultation with stakeholders1         
determines appropriate4  7iv7 ,cost data
 information ,the ,secretary shall      
require those providers of services and 
ambulance service providers selected    
under clause 7ii7 to submit under the   
data collection system under this       
paragraph for each period for which the 
reporting of such data is required1 as  
specified under clause 7i71 data on     
cost1 revenue1 and utilization1 such    
as--  7,i7 data on total revenue1       
including revenues under this title1    
subscription programs1 ,medicaid1 other 
health care plans and self-pay1 public  
funding1 fundraising and donations1     
uncompensated care1 and write-offs2 and 
7,,ii7 data on total cost including     

labor costs 7paid and volunteer71       
operating costs1 administrative costs1  
vehicle and fleet costs1 communications 
costs1 equipment and supplies 7including
 drugs71 maintenance1 building and      
facility costs1 administrative costs1   
local jurisdiction costs1 the cost of   
readiness1 and central office           
administration costs4  7,c7 ,penalty for
 failure to report cost data information
  7i7 ,in general ,beginning on ,january
 #a1 #bjba1 subject to clause 7ii71 a   
#e-percent reduction to payments under  
this part shall be made for a #a-year   
prospective period specified by the     
,secretary to a provider of services or 
ambulance service provider who--  7,i7  
is identified under subparagraph        
7,b77ii7 or 7,d77ii7 as being required  
to submit information under subparagraph
 7,b77iv7 or 7,d77ii71 respectively2 and
  7,,ii7 does not submit such           
information in a timely manner for the  
period specified under subparagraph     
7,b77i7 or 7,d77ii71 respectively4  7ii7

 ,exception ,the ,secretary may suspend 
the payment reduction under clause 7i7  
with respect to a period in the event of
 a natural disaster1 bankruptcy1 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 period4  7,d7 ,ongoing    
cost data collection  7i7 ,revision of  
data collection system ,the ,secretary  
may1 as appropriate1 periodically revise
 the data collection system under this  
paragraph4  7ii7 ,subsequent cost data  
collection  7,i7 ,in general ,in order  
to continue to evaluate the             
appropriateness of payment rates under  
this subsection1 the ,secretary shall1  
for years after #bjbj 7but not more     
frequently than once every #c years71   
require providers of services and       
ambulance service providers to submit   
information described in subparagraph   
7,b77iv7 for a period the ,secretary    

determines appropriate4 ,the penalty    
described in subparagraph 7,c7 shall    
apply to each such subsequent data      
collection period in accordance with    
such subparagraph4  7,,ii7 ,sample ,for 
each period described in subclause 7,i71
 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 period4 ,in determining which       
providers of services and ambulance     
service providers would be required to  
submit information for such period1 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 7,c7 for failing to  
do so in a timely manner4  7,e7         
,consultation ,the ,secretary shall     
consult with stakeholders in carrying   
out the development of the data         
collection system and the collection of 
information under this paragraph1       
including the activities described in   
subparagraphs 7,a7 and 7,d74 ,such      
consultation shall include the use of   
requests for information and other      
mechanisms determined appropriate by the
 ,secretary4  7,f7 ,administration      
,chapter #ce of title #dd1 ,united      
,states ,code1 shall not apply to the   
collection of information required under
 this paragraph4  7,g7 ,limitations on  
review ,there shall be no administrative
 or judicial review under section #ahfi1
 section #ahgh1 or otherwise of the data
 collection system under this paragraph1
 the determination of providers of      
services and ambulance service providers
 required to submit information under   

the data collection system1 or the      
application of the penalty for failure  
to report information under subparagraph
 7,c74  7,h7 ,funding for implementation
 ,for purposes of carrying out          
subparagraph 7,a71 the ,secretary shall 
provide for the transfer1 from the      
,federal ,supplementary ,medical        
,insurance ,trust ,fund under section   
#ahda1 of #a1jjj1jjj to the ,centers for
 ,medicare  ,medicaid ,services ,program
 ,management ,account for fiscal year   
#bjaf4 ,amounts transferred under this  
subparagraph shall remain available     
until expended4  4  #e4 ,treatment of   
ambulance service providers  7a7 ,in    
general ,section #ahcd of the ,social   
,security ,act 7#db ,u4,s4,c4           
#aciem7l771 as amended by section #d1 is
 amended by adding at the end the       
following new paragraph3  7#ba7         
,treatment of ambulance service         
providers as providers of services for  
certain purposes  7,a7 ,provider        
,reimbursement ,review ,board ,for      

purposes of section #ahgh1 an ambulance 
service provider 7as defined in         
paragraph 7#ai77;,e77 shall be treated  
as a provider of services4  7,b7        
,establishment of conditions of         
participation ,an ambulance service     
provider-- 7i7 for purposes of section  
#ahfe7;a77#a71 shall be treated as a    
provider entity2 and  7ii7 shall be     
required to meet such requirements for  
participation under this title as the   
,secretary shall establish by           
regulation4  7,c7 ,use of billing codes 
,an ambulance service provider may1 for 
purposes of this title1 use billing     
codes established for providers of      
services1 if such use is consistent with
 applicable ,federal1 ,state1 or local  
scope of practice requirements4  4  7b7 
,effective date ,the amendment made this
 section shall take effect on ,january  
#a1 #bjah1 and shall apply to an        
ambulance service provider on or after  
such date4