I 
109TH CONGRESS 
1ST SESSION H. R. 2525 
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 HOUSE OF REPRESENTATIVES 
MAY 23, 2005 
Mr. KENNEDY of Minnesota (for himself, Mr. POMEROY, Mr. MORAN of Kan-
sas, and Mr. GILLMOR) introduced the following bill; which was referred 
to the Committee on Energy and Commerce, and in addition to the Com-
mittee on Ways and Means, for a period to be subsequently determined 
by the Speaker, in each case for consideration of such provisions as fall 
within the jurisdiction of the committee concerned 
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. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Rural Access to Emer-
gency Services Act of 2005’’.
SEC. 2. COST-BASED CRITICAL ACCESS HOSPITAL AMBU-
LANCE SERVICES CHANGES. 
(a) IN GENERAL.—Section 1834(l)(8) of the Social 
Security Act (42 U.S.C. 1395m(l)(8)) is amended— 
(1) in subparagraph (B)— 
(A) by striking ‘‘owned and’’; and 
(B) by inserting ‘‘(including when such 
services are provided by the entity under an ar-
rangement with the hospital)’’ after ‘‘hospital’’; 
and 
(2) by striking the comma at the end of sub-
paragraph (B) and all that follows and inserting a 
period. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply to services furnished on or after 
January 1, 2006. 
SEC. 3. PROVIDING APPROPRIATE COVERAGE OF RURAL 
GROUND AMBULANCE SERVICES. 
(a) COVERAGE.—Section 1834(l) of the Social Secu-
rity Act (42 U.S.C. 1395m(l)) is amended by adding at 
the end the following new paragraph: 
‘‘(15) PROVIDING APPROPRIATE COVERAGE OF 
RURAL GROUND AMBULANCE SERVICES.— 
‘‘(A) IN
GENERAL.—The regulations de-
scribed in section 1861(s)(7) shall provide, to 
the extent that any ambulance services (wheth-
er ground or air) may be covered under such 
section, that a rural ground ambulance service 
(as defined in subparagraph (C)) is reimbursed 
under this subsection at the ground ambulance 
rate if the ground ambulance service— 
‘‘(i) is reasonable and necessary based 
on the health condition of the individual 
being transported at or immediately prior 
to the time of the transport; and 
‘‘(ii) complies with equipment and 
crew requirements established by the Sec-
retary. 
‘‘(B) PRUDENT LAYPERSON STANDARD AS 
SATISFACTION
OF
REQUIREMENT
OF
MEDI-
CALLY NECESSARY.—The requirement of sub-
paragraph (A)(i) is deemed to be met for a 
rural ground ambulance service if the request 
for such ambulance service is made after the 
sudden onset of a medical condition that would 
be classified as an emergency medical condition 
under section 1852(d)(3)(B)). 
‘‘(C) RURAL GROUND AMBULANCE SERV-
ICE DEFINED.—For purposes of this paragraph, 
the term ‘rural ground ambulance service’ 
means a ground ambulance service in which the
point of pick up of the individual occurs in a 
rural area identified by the Secretary under 
paragraph (16)(B).’’. 
(b) CONFORMING AMENDMENT.—Section 1861(s)(7) 
of such Act (42 U.S.C. 1395x(s)(7)) is amended by strik-
ing ‘‘section 1834(l)(14)’’ and inserting ‘‘paragraphs (14) 
and (15) of section 1834(l)’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to services furnished on or after 
January 1, 2006. 
SEC. 4. IMPROVEMENT IN PAYMENTS TO RETAIN EMER-
GENCY AND OTHER CAPACITY FOR AMBU-
LANCES IN RURAL AREAS. 
(a) IN GENERAL.—Section 1834(l) of the Social Se-
curity Act (42 U.S.C. 1395m(l)), as amended by section 
3(a), is amended by adding at the end the following new 
paragraph: 
‘‘(16) ADDITIONAL PAYMENTS FOR PROVIDERS 
FURNISHING
AMBULANCE
SERVICES
IN
RURAL 
AREAS.— 
‘‘(A) IN GENERAL.—In the case of ground 
ambulance services furnished on or after Janu-
ary 1, 2006, for which the transportation origi-
nates in a rural area (as determined under sub-
paragraph (B)), the Secretary shall provide for
a percent increase in the base rate of the fee 
schedule for a trip identified under this sub-
section. 
‘‘(B) IDENTIFICATION OF RURAL AREAS.— 
The Secretary, in consultation with the Office 
of Rural Health Policy, shall use the Rural- 
Urban Commuting Areas (RUCA) coding sys-
tem, adopted by that Office, to designate rural 
areas for the purposes of this paragraph. A 
rural area is any area in RUCA levels 2 
through 10 and any unclassified area. 
‘‘(C) TIERING
OF
RURAL
AREAS.—The 
Secretary shall designate 4 tiers of rural areas, 
using a ZIP Code population-based method-
ology generated by the RUCA coding system, as 
follows: 
‘‘(i) TIER 1.—A rural area that is a 
high metropolitan commuting area, in 
which 30 percent or more of the com-
muting flow is to an urban area, as des-
ignated by the Bureau of the Census 
(RUCA level 2). 
‘‘(ii) TIER 2.—A rural area that is a 
low metropolitan commuting area, in which 
less than 30 percent of the commuting flow
is to an urban area or to a large town, as 
designated by the Bureau of the Census 
(RUCA levels 3–6). 
‘‘(iii) TIER 3.—A rural area that is a 
small town core, as designated by the Bu-
reau of the Census, in which no significant 
portion of the commuting flow is to an 
area of population greater than 10,000 
people (RUCA levels 7–9). 
‘‘(iv) TIER 4.—A rural area in which 
there is no dominant commuting flow 
(RUCA level 10) and any unclassified area. 
The Secretary shall consult with the Office of 
Rural Health Policy not less often than every 2 
years to update the designation of rural areas 
in accordance with any changes that are made 
to the RUCA system. 
‘‘(D) PAYMENT ADJUSTMENTS FOR TRIPS 
IN RURAL AREAS.—The Secretary shall adjust 
the payment rate under this section for ambu-
lance trips that originate in each of the tiers es-
tablished in subparagraph (C) according to the 
national average cost of full-cost providers for 
providing ambulance services in each such 
tier.’’.