II 

109TH CONGRESS 

1ST SESSION S. 1108 

To amend title XVIII of the Social Security Act to make improvements 

to payments to ambulance providers in rural areas, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

MAY 24, 2005 

Mr. CONRAD (for himself, Mr. ROBERTS, Mr. HARKIN, and Mr. NELSON of 

Nebraska) 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 make 

improvements to payments to ambulance providers in 

rural areas, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Rural Access to Emer5 gency Services Act of 2005’’. 

6 SEC. 2. COST-BASED CRITICAL ACCESS HOSPITAL AMBU7 LANCE SERVICES CHANGES. 

8 (a) IN GENERAL.—Section 1834(l)(8) of the Social 

9 Security Act (42 U.S.C. 1395m(l)(8)) is amended— 
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1 (1) in subparagraph (B)— 

2 (A) by striking ‘‘owned and’’; and 

3 (B) by inserting ‘‘(including when such 

4 services are provided by the entity under an ar5 rangement with the hospital)’’ after ‘‘hospital’’; 

6 and 

7 (2) by striking the comma at the end of sub8 paragraph (B) and all that follows and inserting a 

9 period. 

10 (b) EFFECTIVE DATE.—The amendments made by 

11 this section shall apply to services furnished on or after 

12 January 1, 2006. 

13 SEC. 3. PROVIDING APPROPRIATE COVERAGE OF RURAL 

14 GROUND AMBULANCE SERVICES. 

15 (a) COVERAGE.—Section 1834(l) of the Social Secu16 rity Act (42 U.S.C. 1395m(l)) is amended by adding at 

17 the end the following new paragraph: 

18 ‘‘(15) PROVIDING APPROPRIATE COVERAGE OF

19 RURAL GROUND AMBULANCE SERVICES.— 

20 ‘‘(A) IN GENERAL.—The regulations de21 scribed in section 1861(s)(7) shall provide, to 

22 the extent that any ambulance services (wheth23 er ground or air) may be covered under such 

24 section, that a rural ground ambulance service 

25 (as defined in subparagraph (C)) is reimbursed 
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1 under this subsection at the ground ambulance 

2 rate if the ground ambulance service— 

3 ‘‘(i) is reasonable and necessary based 

4 on the health condition of the individual 

5 being transported at or immediately prior 

6 to the time of the transport; and 

7 ‘‘(ii) complies with equipment and 

8 crew requirements established by the Sec9 retary. 

10 ‘‘(B) PRUDENT LAYPERSON STANDARD AS

11 SATISFACTION OF REQUIREMENT OF MEDI12 CALLY NECESSARY.—The requirement of sub13 paragraph (A)(i) is deemed to be met for a 

14 rural ground ambulance service if the request 

15 for such ambulance service is made after the 

16 sudden onset of a medical condition that would 

17 be classified as an emergency medical condition 

18 under section 1852(d)(3)(B)). 

19 ‘‘(C) RURAL GROUND AMBULANCE SERV20 ICE DEFINED.—For purposes of this paragraph, 

21 the term ‘rural ground ambulance service’ 

22 means a ground ambulance service in which the 

23 point of pick up of the individual occurs in a 

24 rural area identified by the Secretary under 

25 paragraph (16)(B).’’. 
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1 (b) CONFORMING AMENDMENT.—Section 1861(s)(7) 

2 of such Act (42 U.S.C. 1395x(s)(7)) is amended by strik3 ing ‘‘section 1834(l)(14)’’ and inserting ‘‘paragraphs (14) 

4 and (15) of section 1834(l)’’. 

5 (c) EFFECTIVE DATE.—The amendments made by 

6 this section shall apply to services furnished on or after 

7 January 1, 2006. 

8 SEC. 4. IMPROVEMENT IN PAYMENTS TO RETAIN EMER9 GENCY AND OTHER CAPACITY FOR AMBU10 LANCES IN RURAL AREAS. 

11 (a) IN GENERAL.—Section 1834(l) of the Social Se12 curity Act (42 U.S.C. 1395m(l)), as amended by section 

13 3(a), is amended by adding at the end the following new 

14 paragraph: 

15 ‘‘(16) ADDITIONAL PAYMENTS FOR PROVIDERS

16 FURNISHING AMBULANCE SERVICES IN RURAL

17 AREAS.— 

18 ‘‘(A) IN GENERAL.—In the case of ground 

19 ambulance services furnished on or after Janu20 ary 1, 2006, for which the transportation origi21 nates in a rural area (as determined under sub22 paragraph (B)), the Secretary shall provide for 

23 a percent increase in the base rate of the fee 

24 schedule for a trip identified under this sub25 section. 
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1 ‘‘(B) IDENTIFICATION OF RURAL AREAS.— 

2 The Secretary, in consultation with the Office 

3 of Rural Health Policy, shall use the Rural4 Urban Commuting Areas (RUCA) coding sys5 tem, adopted by that Office, to designate rural 

6 areas for the purposes of this paragraph. A 

7 rural area is any area in RUCA levels 2 

8 through 10 and any unclassified area. 

9 ‘‘(C) TIERING OF RURAL AREAS.—The 

10 Secretary shall designate 4 tiers of rural areas, 

11 using a ZIP Code population-based method12 ology generated by the RUCA coding system, as 

13 follows: 

14 ‘‘(i) TIER 1.—A rural area that is a 

15 high metropolitan commuting area, in 

16 which 30 percent or more of the com17 muting flow is to an urban area, as des18 ignated by the Bureau of the Census 

19 (RUCA level 2). 

20 ‘‘(ii) TIER 2.—A rural area that is a 

21 low metropolitan commuting area, in which 

22 less than 30 percent of the commuting flow 

23 is to an urban area or to a large town, as 

24 designated by the Bureau of the Census 

25 (RUCA levels 3–6). 
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1 ‘‘(iii) TIER 3.—A rural area that is a 

2 small town core, as designated by the Bu3 reau of the Census, in which no significant 

4 portion of the commuting flow is to an 

5 area of population greater than 10,000 

6 people (RUCA levels 7–9). 

7 ‘‘(iv) TIER 4.—A rural area in which 

8 there is no dominant commuting flow 

9 (RUCA level 10) and any unclassified area. 

10 The Secretary shall consult with the Office of 

11 Rural Health Policy not less often than every 2 

12 years to update the designation of rural areas 

13 in accordance with any changes that are made 

14 to the RUCA system. 

15 ‘‘(D) PAYMENT ADJUSTMENTS FOR TRIPS

16 IN RURAL AREAS.—The Secretary shall adjust 

17 the payment rate under this section for ambu18 lance trips that originate in each of the tiers es19 tablished in subparagraph (C) according to the 

20 national average cost of full-cost providers for 

21 providing ambulance services in each such 

22 tier.’’. 

23 (b) REVIEW OF PAYMENTS FOR RURAL AMBULANCE

24 SERVICES AND REPORT TO CONGRESS.— 
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1 (1) REVIEW.—Not later than July 1, 2008, the 

2 Secretary of Health and Human Services shall re3 view the system for adjusting payments for rural 

4 ambulance services under section 1834(l)(16) of the 

5 Social Security Act, as added by subsection (a), to 

6 determine the adequacy and appropriateness of such 

7 adjustments. In conducting such review, the Sec8 retary shall consult with providers and suppliers af9 fected by such adjustments and with representatives 

10 of the ambulance industry generally to determine— 

11 (A) whether such adjustments adequately 

12 cover the additional costs incurred in serving 

13 areas of low population density; and 

14 (B) whether the tiered structure for mak15 ing such adjustments appropriately reflects the 

16 difference in costs of providing services in dif17 ferent types of rural areas. 

18 (2) REPORT.—Not later than January 1, 2009, 

19 the Secretary shall submit to Congress a report on 

20 the review conducted under paragraph (1) together 

21 with any recommendations for revision to the sys22 tems for adjusting payments for ambulance services 

23 in rural areas that the Secretary of Health and 

24 Human Services determines appropriate. 
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1 (c) CONFORMING AMENDMENTS.—(1) Section 

2 1834(l) of the Social Security Act (42 U.S.C. 1395m(l)), 

3 as amended by subsection (a), is amended by adding at 

4 the end the following new paragraph: 

5 ‘‘(17) DESIGNATION OF RURAL AREAS FOR

6 MILEAGE PAYMENT PURPOSES.—In establishing any 

7 differential in the amount of payment for mileage 

8 between rural and urban areas in the fee schedule 

9 established under paragraph (1), the Secretary shall, 

10 in the case of ambulance services furnished on or 

11 after January 1, 2006, identify rural areas in the 

12 same manner as provided in paragraph (16)(B).’’. 

13 (2) Section 1834(l)(12)(A) of such Act (42 U.S.C. 

14 1395m(l)(12)(A)) is amended by striking ‘‘January 1, 

15 2010’’ and inserting ‘‘January 1, 2006’’. 

16 (3) Section 1834(l)(13)(A)(i) of such Act (42 U.S.C. 

17 1395m(l)(13)(A)(i)) is amended by inserting ‘‘(or in the 

18 case of such services furnished in 2006, in a rural area 

19 identified by the Secretary under paragraph (16)(B))’’ 

20 after ‘‘such paragraph’’. 

21 SEC. 5. EXPANDING THE WORK OF MEDICARE QUALITY IM22 PROVEMENT ORGANIZATIONS TO INCLUDE 

23 AMBULANCE PROVIDERS. 

24 (a) APPLICATION TO AMBULANCE PROVIDERS.—Sec25 tion 1154(a)(1) of the Social Security Act (42 U.S.C. 
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1 1320c–3(a)(1)) is amended by inserting ‘‘(including am2 bulance providers)’’ after ‘‘noninstitutional providers’’ in 

3 the matter preceding subparagraph (A). 

4 (b) EFFECTIVE DATE.—The amendment made by 

5 this section shall apply on and after October 1, 2006. 

6 SEC. 6. INCLUDING AMBULANCE PROVIDERS IN THE DEFI7 NITION OF HEALTH CARE PROVIDER FOR 

8 PURPOSES OF THE UNIVERSAL SERVICE 

9 FUND. 

10 (a) IN GENERAL.—Section 254(h)(7)(B) of the Com11 munications Act of 1934 (47 U.S.C. 254(h)(7)(B)) is 

12 amended— 

13 (1) in clause (vi), by striking ‘‘and’’ at the end; 

14 (2) by redesignating clause (vii) as clause (viii); 

15 (3) in clause (viii), as so redesignated, by strik16 ing ‘‘(vi)’’ and inserting ‘‘(vii)’’; and 

17 (4) by inserting after clause (vi) the following 

18 new clause: 

19 ‘‘(vii) ambulance providers; and’’. 

20 (b) EFFECTIVE DATE.—The amendments made by 

21 this section shall take effect on January 1, 2006. 

22 SEC. 7. EMERGENCY MEDICAL SERVICES DEMONSTRATION 

23 PROJECT. 

24 (a) IN GENERAL.— 
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1 (1) IN GENERAL.—The Secretary of Health and 

2 Human Services (in this section referred to as the 

3 ‘‘Secretary’’), acting through the Office of Rural 

4 Health Policy, shall award grants to States to en5 courage such States to make improvements to their 

6 emergency medical services (in this section referred 

7 to as ‘‘EMS’’) systems. 

8 (2) ADMINISTRATION REQUIREMENT.—In order 

9 to be eligible for a grant under this section, a State 

10 shall administer the project jointly through the State 

11 EMS office and the State rural health office. Either 

12 such office may be the lead office for the project. 

13 (3) NUMBER OF GRANTS.—The Secretary shall 

14 award 3 grants under this section. 

15 (4) MAXIMUM AMOUNT.—The Secretary shall 

16 not award a grant under this section in an amount 

17 which exceeds $5,000,000. 

18 (5) DURATION.—The Secretary shall award 

19 grants under this section for a period not to exceed 

20 3 years. 

21 (b) TARGET.—A State that receives a grant under 

22 this section shall, in determining how to allocate the as23 sistance received through such grant— 
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1 (1) target such assistance to geographic areas 

2 that complete community EMS assessments and in3 formed self-determination processes; and 

4 (2) consider progress toward E–911 and WE– 

5 911 system capability. 

6 (c) USE OF FUNDS.—Subject to subsection (b), a 

7 State that receives a grant under this section may use as8 sistance received through such grant for the following: 

9 (1) To integrate the State EMS systems with 

10 the State and local health care delivery system, in11 cluding through exploring opportunities for ex12 panded EMS scopes of practice and piloting EMS13 based rural community health services. 

14 (2) To explore alternative rural EMS funding 

15 mechanisms with State insurance authorities. 

16 (3) To form rural and frontier EMS operational 

17 or service-contracting networks. 

18 (4) To analyze rural and frontier workforce re19 cruitment and retention efforts and to develop state20 wide plans for improvement of such efforts. 

21 (5) To deliver a rural EMS leadership and 

22 management training model which includes EMS 

23 leadership, grant writing, data collection, research, 

24 governing board structure, and management of vol25 unteers. 
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1 (6) To establish at least one full-time position 

2 of State EMS medical director (or an equivalent po3 sition). 

4 (7) To develop flexible models for providing 

5 EMS training and continuing education to rural and 

6 frontier areas and to develop bridge training between 

7 EMS providers and the nursing or other allied 

8 health professions. 

9 (8) To develop State and regional stockpiling 

10 and sharing of expensive training devices, such as 

11 mannequins and patient simulators. 

12 (9) To develop and distribute, in partnership 

13 with public health agencies, data-driven public infor14 mation resources to local EMS providers. 

15 (10) To conduct comprehensive State EMS 

16 communications needs assessments. 

17 (11) To plan, integrate, and regulate, at the 

18 State level, aeromedical, critical care transport and 

19 other statewide or region wide systems of specialty 

20 care and transportation. 

21 (12) To consider the evolving role of telehealth 

22 resources and their application to EMS patient man23 agement and medical oversight. 

24 (13) To implement the National EMS Informa25 tion System. 
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1 (14) To link and integrate, at all levels, EMS 

2 data systems with other relevant health information 

3 systems, such as systems relating to traffic crash 

4 data and other crash data, public health surveil5 lance, the medical examiner, hospital discharge data, 

6 and emergency department data, and including the 

7 Centers for Disease Control and Prevention surveil8 lance monitoring systems. 

9 (d) APPLICATION.— 

10 (1) IN GENERAL.—Each State desiring a grant 

11 under this section shall submit an application to the 

12 Secretary at such time, in such manner, and accom13 panied by such information as the Secretary may 

14 reasonably require. 

15 (2) CONTENTS.—Each application submitted 

16 pursuant to paragraph (1) shall— 

17 (A) describe the activities for which assist18 ance under this section is sought; 

19 (B) provide assurances to the Secretary 

20 that no law exists in the State that would pro21 hibit EMS personnel from practicing in non22 ambulance settings; and 

23 (C) provide such additional assurances as 

24 the Secretary determines to be essential to en-
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1 sure compliance with the requirements of this 

2 section. 

3 (e) AUTHORIZATION OF APPROPRIATIONS.—There is 

4 authorized to be appropriated $15,000,000 to carry out 

5 this section. Not more than 10 percent of amounts re6 ceived under a grant awarded under this section may be 

7 used for administrative expenses. 

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