[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[S. 1108 Introduced in Senate (IS)]







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.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Rural Access to Emergency Services 
Act of 2005''.

SEC. 2. COST-BASED CRITICAL ACCESS HOSPITAL AMBULANCE 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 arrangement with 
                the hospital)'' after ``hospital''; and
            (2) by striking the comma at the end of subparagraph (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 Security 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 described in 
                section 1861(s)(7) shall provide, to the extent that 
                any ambulance services (whether 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 Secretary.
                    ``(B) Prudent layperson standard as satisfaction of 
                requirement of medically necessary.--The requirement of 
                subparagraph (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 service 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 striking ``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 EMERGENCY AND OTHER CAPACITY 
              FOR AMBULANCES IN RURAL AREAS.

    (a) In General.--Section 1834(l) of the Social Security 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 January 1, 2006, for 
                which the transportation originates in a rural area (as 
                determined under subparagraph (B)), the Secretary shall 
                provide for a percent increase in the base rate of the 
                fee schedule for a trip identified under this 
                subsection.
                    ``(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 system, 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 methodology 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 commuting flow is to an 
                        urban area, as designated 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 Bureau 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 ambulance trips that originate 
                in each of the tiers established in subparagraph (C) 
                according to the 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, 2008, the Secretary of 
        Health and Human Services shall review the system for adjusting 
        payments for rural ambulance services under section 1834(l)(16) 
        of the Social Security Act, as added by subsection (a), to 
        determine the adequacy and appropriateness of such adjustments. 
        In conducting such review, the Secretary shall consult with 
        providers and suppliers affected 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 making such 
                adjustments appropriately reflects the difference in 
                costs of providing services in different types of rural 
                areas.
            (2) Report.--Not later than January 1, 2009, the Secretary 
        shall submit to Congress a report on the review conducted under 
        paragraph (1) together with any recommendations for revision to 
        the systems 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:
            ``(17) 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, 2006, identify rural areas in the same manner as provided in 
        paragraph (16)(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, 
2006''.
    (3) Section 1834(l)(13)(A)(i) of such Act (42 U.S.C. 
1395m(l)(13)(A)(i)) is amended by inserting ``(or in the case of such 
services furnished in 2006, in a rural area identified by the Secretary 
under paragraph (16)(B))'' after ``such paragraph''.

SEC. 5. EXPANDING THE WORK OF MEDICARE QUALITY IMPROVEMENT 
              ORGANIZATIONS TO INCLUDE AMBULANCE PROVIDERS.

    (a) Application to Ambulance Providers.--Section 1154(a)(1) of the 
Social Security Act (42 U.S.C. 1320c-3(a)(1)) is amended by inserting 
``(including ambulance providers)'' after ``noninstitutional 
providers'' in the matter preceding subparagraph (A).
    (b) Effective Date.--The amendment made by this section shall apply 
on and after October 1, 2006.

SEC. 6. INCLUDING AMBULANCE PROVIDERS IN THE DEFINITION OF HEALTH CARE 
              PROVIDER FOR PURPOSES OF THE UNIVERSAL SERVICE FUND.

    (a) In General.--Section 254(h)(7)(B) of the Communications Act of 
1934 (47 U.S.C. 254(h)(7)(B)) is amended--
            (1) in clause (vi), by striking ``and'' at the end;
            (2) by redesignating clause (vii) as clause (viii);
            (3) in clause (viii), as so redesignated, by striking 
        ``(vi)'' and inserting ``(vii)''; and
            (4) by inserting after clause (vi) the following new 
        clause:
                            ``(vii) ambulance providers; and''.
    (b) Effective Date.--The amendments made by this section shall take 
effect on January 1, 2006.

SEC. 7. EMERGENCY MEDICAL SERVICES DEMONSTRATION PROJECT.

    (a) In General.--
            (1) In general.--The Secretary of Health and Human Services 
        (in this section referred to as the ``Secretary''), acting 
        through the Office of Rural Health Policy, shall award grants 
        to States to encourage such States to make improvements to 
        their emergency medical services (in this section referred to 
        as ``EMS'') systems.
            (2) Administration requirement.--In order to be eligible 
        for a grant under this section, a State shall administer the 
        project jointly through the State EMS office and the State 
        rural health office. Either such office may be the lead office 
        for the project.
            (3) Number of grants.--The Secretary shall award 3 grants 
        under this section.
            (4) Maximum amount.--The Secretary shall not award a grant 
        under this section in an amount which exceeds $5,000,000.
            (5) Duration.--The Secretary shall award grants under this 
        section for a period not to exceed 3 years.
    (b) Target.--A State that receives a grant under this section 
shall, in determining how to allocate the assistance received through 
such grant--
            (1) target such assistance to geographic areas that 
        complete community EMS assessments and informed self-
        determination processes; and
            (2) consider progress toward E-911 and WE-911 system 
        capability.
    (c) Use of Funds.--Subject to subsection (b), a State that receives 
a grant under this section may use assistance received through such 
grant for the following:
            (1) To integrate the State EMS systems with the State and 
        local health care delivery system, including through exploring 
        opportunities for expanded EMS scopes of practice and piloting 
        EMS-based rural community health services.
            (2) To explore alternative rural EMS funding mechanisms 
        with State insurance authorities.
            (3) To form rural and frontier EMS operational or service-
        contracting networks.
            (4) To analyze rural and frontier workforce recruitment and 
        retention efforts and to develop statewide plans for 
        improvement of such efforts.
            (5) To deliver a rural EMS leadership and management 
        training model which includes EMS leadership, grant writing, 
        data collection, research, governing board structure, and 
        management of volunteers.
            (6) To establish at least one full-time position of State 
        EMS medical director (or an equivalent position).
            (7) To develop flexible models for providing EMS training 
        and continuing education to rural and frontier areas and to 
        develop bridge training between EMS providers and the nursing 
        or other allied health professions.
            (8) To develop State and regional stockpiling and sharing 
        of expensive training devices, such as mannequins and patient 
        simulators.
            (9) To develop and distribute, in partnership with public 
        health agencies, data-driven public information resources to 
        local EMS providers.
            (10) To conduct comprehensive State EMS communications 
        needs assessments.
            (11) To plan, integrate, and regulate, at the State level, 
        aeromedical, critical care transport and other statewide or 
        region wide systems of specialty care and transportation.
            (12) To consider the evolving role of telehealth resources 
        and their application to EMS patient management and medical 
        oversight.
            (13) To implement the National EMS Information System.
            (14) To link and integrate, at all levels, EMS data systems 
        with other relevant health information systems, such as systems 
        relating to traffic crash data and other crash data, public 
        health surveillance, the medical examiner, hospital discharge 
        data, and emergency department data, and including the Centers 
        for Disease Control and Prevention surveillance monitoring 
        systems.
    (d) Application.--
            (1) In general.--Each State desiring a grant under this 
        section shall submit an application to the Secretary at such 
        time, in such manner, and accompanied by such information as 
        the Secretary may reasonably require.
            (2) Contents.--Each application submitted pursuant to 
        paragraph (1) shall--
                    (A) describe the activities for which assistance 
                under this section is sought;
                    (B) provide assurances to the Secretary that no law 
                exists in the State that would prohibit EMS personnel 
                from practicing in non-ambulance settings; and
                    (C) provide such additional assurances as the 
                Secretary determines to be essential to ensure 
                compliance with the requirements of this section.
    (e) Authorization of Appropriations.--There is authorized to be 
appropriated $15,000,000 to carry out this section. Not more than 10 
percent of amounts received under a grant awarded under this section 
may be used for administrative expenses.
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