II 

112TH CONGRESS 

2D SESSION S. 2376 

To recognize and clarify the authority of the States to regulate air ambulance 

medical standards pursuant to their authority over the regulation of 

health care services within their borders, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

APRIL 26, 2012 

Ms. SNOWE (for herself and Ms. CANTWELL) introduced the following bill; 

which was read twice and referred to the Committee on Commerce, 

Science, and Transportation 

A BILL 

To recognize and clarify the authority of the States to regulate air ambulance medical standards pursuant to their 

authority over the regulation of health care services within their borders, 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 ‘‘Air Ambulance Serv5 ices Clarification Act’’. 


jbell on DSK7SPTVN1PROD with BILLS
2 

•S 2376 IS

1 SEC. 2. CLARIFICATION OF STATE AUTHORITY OVER THE 

2 MEDICAL STANDARDS OF AIR AMBULANCE 

3 SERVICES. 

4 (a) IN GENERAL.—Chapter 401 of title 49, United 

5 States Code, is amended by adding at the end the fol6 lowing: 

7 ‘‘SEC. 40131. CLARIFICATION OF STATE AUTHORITY OVER 

8 AIR AMBULANCE MEDICAL STANDARDS AND 

9 MEDICAL CARE RELATED LICENSING RE10 QUIREMENTS. 

11 ‘‘(a) RULE OF CONSTRUCTION.—With respect to an 

12 air ambulance and the medical services provided within an 

13 air ambulance, the term ‘law, regulation, or other provi14 sion having the force and effect of law related to a price, 

15 route, or service of an air carrier’, as used in section 

16 41713, may not be construed to include any medical care 

17 related license and certification requirements based on 

18 medical standards effectuated pursuant to a State’s au19 thority over the licensure and regulation of health care 

20 within its borders. 

21 ‘‘(b) DEFINITIONS.—In this section: 

22 ‘‘(1) AIR AMBULANCE.—The term ‘air ambu23 lance’ means a fixed wing aircraft or a helicopter 

24 used for the provision of care and patient transport. 

25 ‘‘(2) AIR AMBULANCE MEDICAL PERSONNEL.— 

26 The term ‘air ambulance medical personnel’ means 


jbell on DSK7SPTVN1PROD with BILLS
3 

•S 2376 IS

1 the doctors, nurses, paramedics, emergency medical 

2 technicians, physician assistants, respiratory thera3 pists, or other medical specialists providing air am4 bulance services aboard an air ambulance. 

5 ‘‘(3) AIR AMBULANCE OPERATOR.—The term 

6 ‘air ambulance operator’ means a commercial holder 

7 of a part 121 or part 135 certificate that has re8 ceived, from the Federal Aviation Administration— 

9 ‘‘(A) an operations specification A021 (Air 

10 Ambulance Operations—Helicopter); or 

11 ‘‘(B) an operations specification A024 (Air 

12 Ambulance Operations—Airplane). 

13 ‘‘(4) AIR AMBULANCE PROVIDER.—The term 

14 ‘air ambulance provider’ means a program or agency 

15 licensed by the State to provide air ambulance med16 ical services. 

17 ‘‘(5) AIR AMBULANCE SERVICES.—The term 

18 ‘air ambulance services’ means the medical care and 

19 patient transport provided aboard an air ambulance. 

20 ‘‘(6) FEDERAL OPERATING REQUIREMENTS.— 

21 The term ‘Federal operating requirements’ means— 

22 ‘‘(A) the requirements under part A of 

23 subtitle VII of title 49, United States Code; 

24 ‘‘(B) Federal aviation regulations set forth 

25 in title 14, Code of Federal Regulations; and 


jbell on DSK7SPTVN1PROD with BILLS
4 

•S 2376 IS

1 ‘‘(C) the operation specifications and no2 tices to airmen issued by the Federal Aviation 

3 Administration. 

4 ‘‘(7) MEDICAL CARE RELATED LICENSE OR

5 CERTIFICATION.—The term ‘medical care related li6 cense or certification’ means the permission granted 

7 by a State to air ambulance medical personnel, air 

8 ambulance providers, or a specific air ambulance for 

9 providing medical care and transport that— 

10 ‘‘(A) is based solely on, and restricted to, 

11 the State’s authority to set standards for pro12 viding health care within its borders; and 

13 ‘‘(B) is not construed to reference any 

14 Federal Operating Requirements. 

15 ‘‘(8) MEDICALLY-RELATED DISPATCH.—The 

16 term ‘medically-related dispatch’— 

17 ‘‘(A) means a medically-related request for 

18 an air ambulance to provide medical care and 

19 transport to a patient; and 

20 ‘‘(B) does not refer to the flight dispatch 

21 or operational control of an aircraft. 

22 ‘‘(9) REFERRING ENTITIES.—The term ‘refer23 ring entity’ means any entity that makes a request 

24 for medically-related dispatch of an air ambulance or 

25 provides a referral for a provider of air ambulance 


jbell on DSK7SPTVN1PROD with BILLS
5 

•S 2376 IS

1 services, such as a medical institution, an agency 

2 providing emergency medical services, or a first re3 sponder. 

4 ‘‘(10) ROUTINE.—The term ‘routine’ means 

5 medical care and transport that is provided more 

6 than 25 times per year in the applicable State. 

7 ‘‘(11) SCENE.—The term ‘scene’ means the lo8 cation at which the patient’s injury or illness, or 

9 other event resulting in the need for emergency med10 ical care and transport for the patient occurred. 

11 ‘‘(c) MEDICAL AND RELATED MEDICAL CARE

12 STANDARDS TO ENSURE THE CONSISTENT QUALITY OF

13 AIR AMBULANCE SERVICES.—This section shall apply to 

14 medical and related medical care standards that— 

15 ‘‘(1) are required by a State as a condition of 

16 providing— 

17 ‘‘(A) a license or certification to an air am18 bulance, air ambulance providers, and air am19 bulance medical personnel based in such State; 

20 or 

21 ‘‘(B) routine medical care and transport to 

22 patients in such State; and 

23 ‘‘(2) address— 

24 ‘‘(A) the quality of emergency medical care 

25 provided to patients; 


jbell on DSK7SPTVN1PROD with BILLS
6 

•S 2376 IS

1 ‘‘(B) the qualifications and training of air 

2 ambulance medical personnel, scope of practice, 

3 credentialing, and ongoing clinical experience in 

4 critical care settings; 

5 ‘‘(C) the medical direction and clinical 

6 oversight of patient care including qualifications 

7 and credentialing of physicians providing med8 ical direction or clinical oversight; 

9 ‘‘(D) the maintenance of medical records 

10 and data collection and reporting; 

11 ‘‘(E) health outcome and proficiency meas12 ures; 

13 ‘‘(F) participation in patient safety and 

14 quality control initiatives, such as peer review, 

15 utilization review, and error reporting; 

16 ‘‘(G) medically-related accreditation; 

17 ‘‘(H) medical equipment, devices, and sup18 plies on board the air ambulance including the 

19 design, capacity, and performance of such 

20 equipment; 

21 ‘‘(I) sanitation, infection control, decon22 tamination of the air ambulance bay, infectious 

23 hazards, and medical universal precautions; 

24 ‘‘(J) the design and configuration of the 

25 air ambulance medical compartment for the 


jbell on DSK7SPTVN1PROD with BILLS
7 

•S 2376 IS

1 provision of quality medical care that allows 

2 adequate access to the patient for the purposes 

3 of resuscitation and emergency procedures con4 sistent with the medical mission, medical equip5 ment, and medical supplies by the medical per6 sonnel during flight without becoming unse7 cured; 

8 ‘‘(K) medically-related air ambulance fea9 tures and capability specifications necessary 

10 and appropriate for the provision of quality 

11 medical care related to— 

12 ‘‘(i) permanently installed medically13 related climate control system require14 ments capable of meeting specified tem15 perature settings; 

16 ‘‘(ii) the use of materials in the air 

17 ambulance that are appropriate for a prop18 er patient care environment; 

19 ‘‘(iii) providing medically appropriate 

20 care and transport to patients, including 

21 special populations, such as neonatal or pe22 diatric patients; 

23 ‘‘(iv) ensuring sufficient electrical sup24 ply to adequately power required medical 

25 equipment without reliance on medical 


jbell on DSK7SPTVN1PROD with BILLS
8 

•S 2376 IS

1 equipment batteries and without compro2 mising the ambulance power to lift or fly; 

3 ‘‘(L) patient safety standards related to— 

4 ‘‘(i) loading or unloading patients; 

5 and 

6 ‘‘(ii) refueling with a patient on 

7 board; 

8 ‘‘(M) communication capabilities— 

9 ‘‘(i) between air ambulance medical 

10 personnel and public safety, emergency 

11 medical service agencies and hospitals; and 

12 ‘‘(ii) that allow for functional internal 

13 communication within the air ambulance 

14 for medical purposes; and 

15 ‘‘(N) coordination and oversight over a 

16 State‘s emergency medical system and the air 

17 ambulance provider’s participation in such sys18 tem, such as standards that— 

19 ‘‘(i) designate levels of medical capa20 bility, medical appropriateness, and med21 ical staffing of air ambulances, such as 

22 medical staffing configurations for par23 ticular medical missions or the different 

24 medical-related licenses or certifications re25 quired for air ambulances and air ambuVerDate Mar 15 2010 00:48 May 02, 2012 Jkt 019200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S2376.IS S2376

jbell on DSK7SPTVN1PROD with BILLS
9 

•S 2376 IS

1 lance medical personnel that provide ad2 vanced life support, critical care, or spe3 cialty care; 

4 ‘‘(ii) establish medically-related dis5 patch and destination protocols for pa6 tients with emergency medical conditions 

7 being transported that coordinate requests 

8 for air ambulance service response based 

9 on the medical appropriateness of the air 

10 ambulance to meet the patient’s need for 

11 medical care and transport to the appro12 priate medical institution consistent with 

13 patient condition, such as protocols for de14 termining the appropriate— 

15 ‘‘(I) mode of transport (ground 

16 versus air) in accordance with avail17 able evidence-based triage criteria; 

18 ‘‘(II) available air ambulance to 

19 transport a patient in accordance with 

20 its capability to meet the patient’s 

21 medical need; and 

22 ‘‘(III) medical institution to re23 ceive the patient, such as trauma, 

24 burn, chest pain, or stroke center; 


jbell on DSK7SPTVN1PROD with BILLS
10 

•S 2376 IS

1 ‘‘(iii) require the air ambulance pro2 vider to identify its primary service area 

3 and its service availability and any updates 

4 or changes to such area or availability for 

5 the purpose of coordination of ambulance 

6 response; 

7 ‘‘(iv) require an air ambulance oper8 ator agency to identify the medical institu9 tions the air ambulance can reach from its 

10 base location within a specified period of 

11 time without refueling; 

12 ‘‘(v) require the air ambulance opera13 tors to provide, for the purpose of coordi14 nation of patient care and medical decision 

15 making, reasonably accurate estimated 

16 times of arrival with due consideration of 

17 safety measures, current location, and sta18 tus of available air ambulances to referring 

19 entities; and 

20 ‘‘(vi) prohibit practices which may im21 pede the proper functioning of such sys22 tem, such as— 

23 ‘‘(I) referring entities serially 

24 contacting air ambulance providers 

25 until an air ambulance provider 


jbell on DSK7SPTVN1PROD with BILLS
11 

•S 2376 IS

1 agrees to medically-related dispatch 

2 (also known as helicopter shopping); 

3 ‘‘(II) indicating false or inac4 curate ambulance availability or esti5 mated times of arrival to a referring 

6 entity; 

7 ‘‘(III) exclusive agreements be8 tween hospitals and air ambulance 

9 providers or between air ambulance 

10 providers and referring entities; 

11 ‘‘(IV) proffers of gifts by air am12 bulance providers to referring entities 

13 other than solely for medical edu14 cation purposes; or 

15 ‘‘(V) representations by air am16 bulance providers to referring entities 

17 that the air ambulance and the air 

18 ambulance medical personnel can pro19 vide a level of care beyond its scope of 

20 medical capability. 

21 ‘‘(d) LIMITATIONS.—A medical or related medical 

22 care standard is not within the scope set forth in sub23 section (c) if such standard has the effect of— 


jbell on DSK7SPTVN1PROD with BILLS
12 

•S 2376 IS

1 ‘‘(1) superseding, or being inconsistent with, 

2 any Federal operating requirement with respect to 

3 aviation safety; 

4 ‘‘(2) denying licensure to an air ambulance, air 

5 ambulance medical personnel, or air ambulance pro6 vider that otherwise meets such standard from pro7 viding routine care and transport to a patient be8 tween 2 locations within a State based solely on the 

9 ambulance’s base geographic location being within 

10 another State; 

11 ‘‘(3) preventing an air ambulance licensed in 1 

12 State from transporting a patient into or out of an13 other state on a non-routine basis; or 

14 ‘‘(4) impeding intrastate transport of a patient 

15 as a result of the delegation by the State to a polit16 ical subdivision within the State of the development 

17 or oversight of the standard. 

18 ‘‘(e) LIMITATION OF SCOPE.—The absence of any 

19 medical standard from subsection (c) does not create an 

20 inference that such standard is or is not a ‘law, regulation 

21 or other provision having the force and effect of law re22 lated to a price, route or service of an air carrier’.’’. 

23 (b) CONFORMING AMENDMENT.—The table of con24 tents for such chapter 401 is amended by adding at the 

25 end the following: 


jbell on DSK7SPTVN1PROD with BILLS
13 

•S 2376 IS

‘‘40131. Clarification of State authority over air ambulance medical standards 

and medical care related licensing requirements.’’. 

Æ 


jbell on DSK7SPTVN1PROD with BILLS