II 

115TH CONGRESS 

1ST SESSION S. 2121 

To amend title XVIII of the Social Security Act to require reporting of 

certain data by providers and suppliers of air ambulance services for 

purposes of reforming reimbursements for such services under the Medicare program, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

NOVEMBER 14, 2017 

Mr. HELLER (for himself, Mr. BENNET, and Mr. GARDNER) 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 require 

reporting of certain data by providers and suppliers of 

air ambulance services for purposes of reforming reimbursements for such services under the Medicare program, 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 ‘‘Ensuring Access to 

5 Air Ambulance Services Act of 2017’’. 


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1 SEC. 2. AIR AMBULANCE DATA REPORTING PROGRAM AND 

2 VALUE-BASED PURCHASING PROGRAM. 

3 Section 1834(l) of the Social Security Act (42 U.S.C. 

4 1395m(l)) is amended— 

5 (1) in paragraph (3)(B), by striking ‘‘subpara6 graph (C)’’ and inserting ‘‘subparagraph (C) and 

7 paragraphs (17) and (20)’’; 

8 (2) in paragraph (3)(C), by inserting ‘‘(other 

9 than 2018)’’ after ‘‘each subsequent year’’; and 

10 (3) by adding at the end the following new 

11 paragraphs: 

12 ‘‘(17) AIR AMBULANCE DATA REPORTING PRO13 GRAM.— 

14 ‘‘(A) SUBMISSION OF COST DATA.—With 

15 respect to 2019 and each subsequent year, each 

16 supplier or provider of air ambulance services 

17 shall submit to the Secretary data specified 

18 under subparagraph (B) for air ambulance 

19 services furnished by such provider or supplier 

20 during such year. Such data shall be submitted 

21 in a form and manner, and on an annual basis, 

22 as specified by the Secretary for purposes of 

23 this subparagraph. 

24 ‘‘(B) COST DATA.—For purposes of report25 ing data for air ambulance services furnished 


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1 during a year, the data described in this sub2 paragraph are cost data on the following: 

3 ‘‘(i) Maintenance of aircrafts. 

4 ‘‘(ii) Medical supplies and equipment. 

5 ‘‘(iii) Fuel. 

6 ‘‘(iv) Employee expenses. 

7 ‘‘(v) Recurring training relating to 

8 aviation, maintenance, communication, and 

9 clinical. 

10 ‘‘(vi) Rent and utilities. 

11 ‘‘(vii) Communications. 

12 ‘‘(viii) Travel. 

13 ‘‘(ix) Hull and aviation liability insur14 ance, life insurance, and professional mal15 practice insurance. 

16 ‘‘(x) Marketing. 

17 ‘‘(xi) Supplies and equipment. 

18 ‘‘(xii) Overhead support. 

19 ‘‘(xiii) Aircraft ownership expenses. 

20 ‘‘(xiv) Depreciation. 

21 ‘‘(xv) Safety enhancement capital 

22 costs. 

23 ‘‘(xvi) Safety enhancement recurring 

24 costs. 


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1 ‘‘(C) CONSULTATION RELATING TO COST

2 REPORTS.—For purposes of this paragraph, the 

3 Secretary shall consult with suppliers and pro4 viders of air ambulance services to develop a 

5 cost reporting instrument and further define 

6 the data specified under subparagraph (B) 

7 through instructions. 

8 ‘‘(D) SUBMISSION OF QUALITY DATA.— 

9 With respect to 2020 and each subsequent year, 

10 each supplier or provider of air ambulance serv11 ices shall submit to the Secretary data specified 

12 under subparagraph (E) for air ambulance 

13 services furnished by such supplier or provider 

14 during such year. Such data shall be submitted 

15 in a form and manner, and on an annual basis, 

16 as specified by the Secretary for purposes of 

17 this subparagraph. 

18 ‘‘(E) QUALITY DATA.—For purposes of re19 porting data for air ambulance services fur20 nished during a year, the data described in this 

21 subparagraph are quality data on the following 

22 measures: 

23 ‘‘(i) Mechanical ventilator use in pa24 tients with advanced airways. 


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1 ‘‘(ii) Interpretation of 12-lead electro2 cardiogram documented on patient care 

3 record for those transported with primary 

4 cardiac diagnoses. 

5 ‘‘(iii) Continuous waveform capnogra6 phy for mechanically ventilated patients. 

7 ‘‘(iv) Advanced airway established 

8 without newly developed hypoxia or hypo9 tension. 

10 ‘‘(v) Tracheal intubation verified with 

11 capnography and direct visualization, chest 

12 radiograph, or symmetric breath sounds. 

13 ‘‘(F) CONSEQUENCE FOR NOT REPORTING

14 QUALITY DATA FOR VALUE-BASED PUR15 CHASING.— 

16 ‘‘(i) IN GENERAL.—With respect to 

17 ambulance services furnished by a provider 

18 or supplier of air ambulance services dur19 ing a payment year (beginning with 2024), 

20 if such provider or supplier does not sub21 mit to the Secretary data specified under 

22 subparagraph (E) for the performance pe23 riod for such year (as defined in paragraph 

24 (20)(F)), the Secretary shall provide for a 

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1 centage increase determined under para2 graph (3)(B), after application of para3 graphs (3)(C) and (19) for such payment 

4 year. 

5 ‘‘(ii) APPLICATION.—The reduction 

6 under clause (i) shall apply only with re7 spect to the year involved and the Sec8 retary shall not take into account such in9 crease in computing the payment amount 

10 under the fee schedule under this sub11 section for a subsequent year. 

12 ‘‘(iii) DISTRIBUTION.—For purposes 

13 of paragraph (20)(D)(iii)(III), of the total 

14 amount of reductions pursuant to clause 

15 (i) for a payment year— 

16 ‘‘(I) 50 percent of such reduc17 tions shall be made available for pur18 poses of performance payments under 

19 paragraph (20) for such payment 

20 year; and 

21 ‘‘(II) 50 percent shall be trans22 ferred to the Federal Hospital Insur23 ance Trust Fund under section 1817. 

24 ‘‘(G) DATA DISCLOSURES.—The Secretary 

25 shall provide, with respect to data submitted 


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1 under subparagraph (D) by a supplier or pro2 vider of air ambulance services— 

3 ‘‘(i) with respect to 2020, on a con4 fidential basis to such supplier or provider, 

5 information with respect to such data and 

6 year, including a comparison of the results 

7 of such data submitted by such supplier or 

8 provider to the national average, with re9 spect to such data reported; and 

10 ‘‘(ii) with respect to a subsequent 

11 year, for the public disclosure of such in12 formation with respect to such subsequent 

13 year, including the comparison described in 

14 clause (i) of such data with respect to such 

15 subsequent year. 

16 ‘‘(H) REPORTS.— 

17 ‘‘(i) BY SECRETARY.—Not later than 

18 July 1, 2021, subject to clause (iii), the 

19 Secretary shall submit to Congress a re20 port on the data described in subpara21 graphs (B) and (E) submitted to the Sec22 retary. 

23 ‘‘(ii) BY COMPTROLLER GENERAL.— 

24 Not later than July 1, 2021, subject to 

25 clause (iii), the Comptroller General of the 


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1 United States shall submit to Congress a 

2 report on the data described in subpara3 graph (B) and subparagraph (E) sub4 mitted under this paragraph. Such report 

5 shall include an analysis of cost variation 

6 to providers and supplier of air ambulance 

7 services by geography and provider or sup8 plier status and a recommendation on the 

9 adequate amount of reimbursement under 

10 this title to providers and suppliers of air 

11 ambulance services for furnishing such 

12 services that would reflect operational costs 

13 of such providers and suppliers and pre14 serve access to critical air medical services 

15 and such other recommendations as the 

16 Comptroller General deems appropriate. 

17 ‘‘(iii) LIMITATION.—The reports sub18 mitted under subclauses (i) and (ii) shall 

19 not include any information that the Sec20 retary or Comptroller General, respectively, 

21 determines is proprietary. 

22 ‘‘(18) TEMPORARY INCREASE IN PAYMENT FOR

23 AIR AMBULANCE SERVICES.— 

24 ‘‘(A) INCREASE.— 


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1 ‘‘(i) IN GENERAL.—Subject to sub2 paragraph (B), in the case of air ambu3 lance services— 

4 ‘‘(I) furnished during 2018, the 

5 Secretary shall provide for a percent 

6 increase of 12 percent in the base rate 

7 of the fee schedule established under 

8 this subsection for such air ambulance 

9 services; and 

10 ‘‘(II) furnished during 2019 and 

11 2020, the Secretary shall provide for 

12 a percent increase of 20 percent in 

13 the base rate of the fee schedule es14 tablished under this subsection for 

15 such air ambulance services. 

16 ‘‘(ii) APPLICATION.—The increase 

17 under clause (i) shall apply only with re18 spect to the year involved and the Sec19 retary shall not take into account such in20 crease in computing the payment amount 

21 under the fee schedule under this sub22 section for a subsequent year. 

23 ‘‘(B) NO INCREASE FOR PROVIDERS AND

24 SUPPLIERS THAT DO NOT REPORT DATA.—The 

25 Secretary shall not provide for the percent inVerDate Sep 11 2014 23:44 Nov 17, 2017 Jkt 079200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S2121.IS S2121

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1 crease under subparagraph (A) in the base rate 

2 of the fee schedule established under this sub3 section— 

4 ‘‘(i) with respect to air ambulances 

5 services furnished by a supplier or provider 

6 of air ambulances services during 2019, 

7 unless the provider or supplier submits to 

8 the Secretary cost data in accordance with 

9 paragraph (17)(A) for such year; and 

10 ‘‘(ii) with respect to air ambulances 

11 services furnished by a supplier or provider 

12 of air ambulances services during 2020, 

13 unless the provider or supplier submits to 

14 the Secretary cost data in accordance with 

15 paragraph (17)(A) and quality data in ac16 cordance with paragraph (17)(D) for such 

17 year. 

18 ‘‘(19) REBASING AIR AMBULANCE BASE

19 RATE.—The Secretary shall, through rulemaking, 

20 provide for an update to the base rate of the fee 

21 schedule established under this subsection for air 

22 ambulance services, which shall be applied beginning 

23 with air ambulance services furnished during 2021, 

24 so that such rate reflects the actual costs of pro25 viding air ambulance services, consistent with cost 


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1 data submitted under paragraph (17)(A). In car2 rying out the previous sentence, the Secretary shall 

3 ensure that the aggregate data, methodology, and 

4 rationale applied for determining the updated base 

5 rate shall be made publicly available through rule6 making. The preceding sentence shall not be applied 

7 in a budget neutral manner. 

8 ‘‘(20) VALUE-BASED PURCHASING PROGRAM.— 

9 ‘‘(A) IN GENERAL.—The Secretary shall 

10 establish an air ambulance services value-based 

11 purchasing program (in this paragraph referred 

12 to as the ‘Program’). Under the Program, the 

13 Secretary shall— 

14 ‘‘(i) for a performance period (as de15 fined in subparagraph (F)) with respect to 

16 a payment year (beginning with 2024), de17 termine the performance of each provider 

18 or supplier of air ambulance services, with 

19 respect to each quality measure described 

20 in paragraph (17)(E); 

21 ‘‘(ii) for each such performance pe22 riod, establish performance benchmarks in 

23 accordance with subparagraph (B); 

24 ‘‘(iii) for each such performance pe25 riod and each quality measure described in 


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1 paragraph (17)(E), establish a perform2 ance score for each provider or supplier of 

3 air ambulance services, that is determined 

4 by measuring the performance of such pro5 vider or supplier described in clause (i), 

6 with respect to each quality measure de7 scribed in such clause, against the per8 formance benchmark established under 

9 subparagraph (B) for such quality meas10 ure; 

11 ‘‘(iv) for each such performance pe12 riod and provider or supplier of air ambu13 lance services, determine a composite per14 formance quality score, in accordance with 

15 subparagraph (C); 

16 ‘‘(v) for each such performance pe17 riod, rank each provider or supplier of air 

18 ambulance services, based on the composite 

19 performance quality score of such provider 

20 or supplier for such period (as determined 

21 under subparagraph (C)), in order from 

22 highest to lowest; and 

23 ‘‘(vi) for each such payment year 

24 specify a performance payment percentage 

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1 paragraph (D)(ii), for each provider or 

2 supplier of air ambulance services to be ap3 plied under subparagraph (D)(i). 

4 ‘‘(B) PERFORMANCE BENCHMARKS.— 

5 Under the Program, for each performance pe6 riod with respect to a payment year (beginning 

7 with payment year 2024), the Secretary shall 

8 establish a nationwide performance benchmark 

9 for each quality measure described in para10 graph (17)(E). Such a benchmark, with respect 

11 to such a quality measure, shall be the average 

12 of the performance scores for all such providers 

13 and suppliers for such measure. 

14 ‘‘(C) COMPOSITE PERFORMANCE QUALITY

15 SCORES.—Under the Program, for each per16 formance period with respect to a payment year 

17 (beginning with payment year 2024), the Sec18 retary shall determine a composite performance 

19 quality score for each provider or supplier of air 

20 ambulance services, based on the cumulative 

21 performance scores determined under subpara22 graph (A)(iii) for such provider or supplier and 

23 performance period. For purposes of ranking 

24 under subparagraph (A)(v), a provider or sup25 plier of air ambulance services who does not 


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1 submit required data to determine performance 

2 under this paragraph for a performance period 

3 for a year shall be treated as receiving a com4 posite performance quality score of zero under 

5 this subparagraph for such period and shall be 

6 ranked accordingly under subparagraph (A)(v). 

7 ‘‘(D) PERFORMANCE PAYMENT.— 

8 ‘‘(i) IN GENERAL.—With respect to 

9 ambulance services furnished by a provider 

10 or supplier of air ambulance services dur11 ing a payment year (beginning with 2024), 

12 the Secretary shall apply a performance 

13 payment percentage point adjustment to 

14 the percentage increase determined under 

15 paragraph (3)(B), after application of 

16 paragraphs (3)(C), (17)(F), and (19) and 

17 subparagraph (E) for a payment year (be18 ginning with 2024). 

19 ‘‘(ii) PERFORMANCE PAYMENT PER20 CENTAGE POINT ADJUSTMENT.—The Sec21 retary shall, in accordance with clause (iii), 

22 specify a performance payment percentage 

23 point adjustment for a provider or supplier 

24 of air ambulance services for a payment 


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1 year (beginning with 2024) which may in2 clude a zero percentage. 

3 ‘‘(iii) REQUIREMENTS.—In specifying 

4 the performance payment percentage point 

5 adjustment for a provider or supplier of air 

6 ambulance services for a payment year 

7 under clause (i), the Secretary shall ensure 

8 that— 

9 ‘‘(I) such adjustment is based on 

10 the ranking of the provider or supplier 

11 under subparagraph (A)(v) for the 

12 performance period for such payment 

13 year; 

14 ‘‘(II) the application of all such 

15 adjustments in such fiscal year results 

16 in an appropriate distribution of per17 formance payment incentives applied 

18 under this paragraph such that— 

19 ‘‘(aa) providers and sup20 pliers of air ambulance services 

21 with the highest rankings under 

22 subparagraph (A)(v) receive the 

23 highest payment increases under 

24 clause (i); and 


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1 ‘‘(bb) providers and sup2 pliers of air ambulance services 

3 with the lowest rankings under 

4 subparagraph (A)(v) receive the 

5 lowest payment increases under 

6 clause (i), which may include 

7 zero; and 

8 ‘‘(III) the total amount of in9 creases in payment under this sub10 section for all providers and suppliers 

11 of air ambulance services, pursuant to 

12 this subparagraph, in such payment 

13 year shall be equal to the sum of the 

14 total amount, as estimated by the Sec15 retary, of the reductions to payments 

16 under this subsection for such pay17 ment year pursuant to subparagraph 

18 (E) and the total amount, as esti19 mated by the Secretary, of the reduc20 tions made under paragraph 

21 (17)(F)(i) and made available under 

22 paragraph (17)(F)(iii)(I) for purposes 

23 of performance payments under this 

24 paragraph for such payment year. 


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1 ‘‘(E) FUNDING FOR PERFORMANCE INCEN2 TIVE ADJUSTMENTS.— 

3 ‘‘(i) IN GENERAL.—With respect to 

4 air ambulance services furnished by a sup5 plier or provider of air ambulance services 

6 during 2024 or a subsequent year, the Sec7 retary, after determining the percentage 

8 increase under paragraph (3)(B), and after 

9 application of paragraphs (3)(C), (17), and 

10 (19), shall reduce such percentage increase 

11 for payments under the fee schedule under 

12 this subsection otherwise applicable to such 

13 provider or supplier for services furnished 

14 by such provider or supplier during such 

15 year by the applicable percent (as defined 

16 in clause (ii)). The Secretary shall make 

17 such reductions for all providers and sup18 pliers of air ambulance services in the year 

19 involved, regardless of whether or not the 

20 provider or supplier has been determined 

21 by the Secretary to have earned a perform22 ance payment percentage point adjustment 

23 under subparagraph (D) for such year. 

24 ‘‘(ii) APPLICABLE PERCENT.—For 

25 purposes of clause (i), the term ‘applicable 


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1 percent’ means, with respect to 2024 and 

2 succeeding years, 2 percent. 

3 ‘‘(F) PERFORMANCE PERIOD.—For pur4 poses of this paragraph, the term ‘performance 

5 period’ means, with respect to a payment year, 

6 the previous year (or, if specified by the Sec7 retary, portion or portions of such previous 

8 year).’’. 

Æ 


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