text: 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.''.
target: 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.
feat_title: Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2014