‘‘(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 
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national average cost of full-cost providers for 
providing ambulance services in each such 
tier.’’. 
(b) REVIEW OF PAYMENTS FOR RURAL AMBULANCE 
SERVICES AND REPORT TO CONGRESS.— 
(1) REVIEW.—Not later than July 1, 2009, the 
Secretary of Health and Human Services shall re-
view the system for adjusting payments for rural 
ambulance services under section 1834(l)(15) of the 
Social Security Act, as added by subsection (a), to 
determine the adequacy and appropriateness of such 
adjustments. In conducting such review, the Sec-
retary shall consult with providers and suppliers af-
fected by such adjustments and with representatives 
of the ambulance industry generally to determine— 
(A) whether such adjustments adequately 
cover the additional costs incurred in serving 
areas of low population density; and 
(B) whether the tiered structure for mak-
ing such adjustments appropriately reflects the 
difference in costs of providing services in dif-
ferent types of rural areas. 
(2) REPORT.—Not later than January 1, 2010, 
the Secretary shall submit to Congress a report on 
the review conducted under paragraph (1) together 
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with any recommendations for revision to the sys-
tems for adjusting payments for ambulance services 
in rural areas that the Secretary of Health and 
Human Services determines appropriate. 
(c) 
CONFORMING
AMENDMENTS.—(1) 
Section 
1834(l) of the Social Security Act (42 U.S.C. 1395m(l)), 
as amended by subsection (a), is amended by adding at 
the end the following new paragraph: 
‘‘(16) DESIGNATION
OF
RURAL
AREAS
FOR 
MILEAGE PAYMENT PURPOSES.—In establishing any 
differential in the amount of payment for mileage 
between rural and urban areas in the fee schedule 
established under paragraph (1), the Secretary shall, 
in the case of ambulance services furnished on or 
after January 1, 2007, identify rural areas in the 
same manner as provided in paragraph (15)(B).’’. 
(2) Section 1834(l)(12)(A) of such Act (42 U.S.C. 
1395m(l)(12)(A)) is amended by striking ‘‘January 1, 
2010’’ and inserting ‘‘January 1, 2007’’. 
(3) Section 1834(l)(13)(A)(i) of such Act (42 U.S.C. 
1395m(l)(13)(A)(i)) is amended— 
(A) by inserting ‘‘(or in the case of such serv-
ices furnished in 2007, in a rural area identified by 
the Secretary under paragraph (15)(B))’’ after 
‘‘such paragraph’’; and 
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