,i  #aai? ,,congress  #b;d ,session  ,h4
 ,r4 #iigj  ,,9 ,,! ,,h\se ,,(          
,,repres5tatives  ,july #bg1 #bjbf,mr4  
,pflug] 7= himself1 ,ms4 ,tokuda1 ,ms4  
,van ,duyne1 ,ms4 ,s*ri]1 ,mr4 ,joyce ( 
,p5nsylvania1 ,mr4 ,s*neid]1 ,ms4       
,t5ney1 & ,ms4 ,sewell7 introduc$ !     
foll[+ bill2 :i* 0 ref]r$ to !          
,committee on ,en]gy & ,comm]ce1 & 9    
addition to ! ,committee on ,ways &     
,means1 = a p]iod to be subsequ5tly     
det]m9$ by ! ,speak]1 9 ea* case =      
consid]ation ( su* provisions z fall )9 
! jurisdiction ( ! committee conc]n$  ,a
 ,,bill  ,to am5d title ,,xviii ( !     
,social ,security ,act to ensure        
appropriate paym5ts = ambulance s]vices 
"u ! ,m$ic>e program4  #a4 ,%ort title  
,?is ,act may be cit$ z ! ,reimburs+    
,em]g5cy ,s]vices = ,critical ,urg5t    
,enc\nt]s ,act ( #bjbf or ,,rescue ,act 
( #bjbf4  #b4 ,ambulance s]vices paym5ts
 ,section #ahcd7l7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #aciem7l77 is      
am5d$-- 7#a7 9 p>agraph 7#a7--  7,a7 by 

ins]t+ 1 = ye>s be=e #bjbg1 aft] "u ?is 
"p ?r\gh2 &  7,b7 by ins]t+ 7& = ea*    
ye>1 beg9n+ ) #bjbg1 by regulation7 aft]
 title #e1 ,unit$ ,/ates ,code12  7#b7 9
 p>agraph 7#b77;,d71 by ins]t+ &1 beg9n+
 = #bjbh1 9 accordance ) p>agraph 7#ah71
 det]m9e & apply updat$ paym5t am\nts 7z
 def9$ 9 subp>agraph 7,a77ii7 ( su*     
p>agraph7 & ! adju/m5ts describ$ 9 su*  
p>agraph aft] & o!r relevant factors2   
7#c7 9 p>agraph 7#c7--  7,a7 9          
subp>agraph 7,b7-- 7i7 by ins]t+ 7be=e  
#bjbh7 aft] ea* subsequ5t ye>2 &  7ii7  
by /rik+ & aft] ! semicolon2  7,b7 9    
subp>agraph 7,c7--  7i7 by ins]t+ 7be=e 
#bjbh7 aft] ea* subsequ5t ye>2 &  7ii7  
by /rik+ ! p]iod at ! end & ins]t+ a    
semicolon2 &  7,c7 by ins]t+ at ! end ! 
foll[+3  7,d7 = s]vices furni%$ 9 #bjbh1
 sub/itute ! updat$ paym5t am\nts 7z    
def9$ 9 p>agraph 7#ah77;,a77ii77 = su*  
s]vices z ! paym5t am\nts provid$ "u !  
fee s*$ule = su* s]vices2 &  7,e7 set ! 
paym5t am\nts provid$ "u ! fee s*$ule = 
s]vices furni%$ 9 #bjbi & ea* subsequ5t 

ye> at am\nts equal to ! paym5t am\nts  
"u ! fee s*$ule = s]vices furni%$ dur+ !
 previ\s ye>1 updat$ by ! adju/m5ts or  
increase applicable to su* ye> 9        
accordance ) clause 7ii7 or 7iii71      
respectively1 ( p>agraph 7#ah77;,b74  2 
7#d7 9 p>agraph 7#d71 by ins]t+ includ+ 
= purposes ( c>ry+ out ! provisions (   
p>agraph 7#ah71 aft] "u ?is subsection12
  7#e7 9 p>agraph 7#ae71 by /rik+ !     
prec$+ provisions ( aft] am\nt o!rwise  
applicable "u2  7#f7 9 p>agraph 7#ag7-- 
7,a7 9 subp>agraph 7,d7-- 7i7 9 clause  
7i7--  7,i7 by ins]t+ 7or1 9 ! case ( a 
provid] or suppli] ( air ambulance      
s]vices1 beg9n+ ,janu>y #a ( ! ye>      
subsequ5t to ! fir/ ye> = :i* su*       
provid]s & suppli]s are requir$ to      
submit in=mation pursuant to subp>agraph
 7,e77ii77,,ii771 aft] ,beg9n+ ,janu>y  
#a1 #bjbb12  7,,ii7 by r$esignat+       
subclauses 7,i7 & 7,,ii7 z items 7aa7 & 
7bb71 respectively1 & mov+ ! m>g9 ( ea* 
su* item1 z r$esignat$1 #b ems to ! "r2 
7,,iii7 by /rik+ 7z def9$ 9 clause 7ii77

 to a provid] or suppli] ( gr\nd        
ambulance s]vices & ins]t+ 7z def9$ 9   
clause 7ii77--  7,i7 to a provid] or    
suppli] ( gr\nd ambulance s]vices  2    
7,,iv7 by /rik+ at ! end ! p]iod &      
ins]t+ 2 &2 &  7,v7 by add+ at ! end !  
foll[+ new subclause3  7,,ii7 to a      
provid] or suppli] ( air ambulance      
s]vices t--  7aa7 is requir$ to submit  
in=mation = a ye> det]m9$ by ! ,secret>y
 "u subp>agraph 7,e77ii77,,ii72 &  7bb7 
does n suffici5tly submit su* in=mation1
 z det]m9$ by ! ,secret>y4  2  7ii7 9   
clause 7ii7-- 7,i7 by ins]t+ or a       
provid] or suppli] ( air ambulance      
s]vices aft] ) respect to a provid] or  
suppli] ( gr\nd ambulance s]vices2      
7,,ii7 by /rik+ made a det]m9ation "u   
clause 7i77,,ii7 & ins]t+ made--  7,i7 9
 ! case ( a provid] or suppli] ( gr\nd  
ambulance s]vices1 a det]m9ation "u     
clause 7i77,i77bb7  2  7,,iii7 by /rik+ 
at ! end ! p]iod & ins]t+ 2 or2 &       
7,,iv7 by add+ at ! end ! foll[+ new    
subclause3  7,,ii7 9 ! case ( a provid] 

or suppli] ( air ambulance s]vices1 a   
det]m9ation "u clause 7i77,,ii77bb7 t ! 
provid] or suppli] ( air ambulance      
s]vices fail$ to suffici5tly submit     
in=mation z describ$ 9 clause           
7i77,,ii77aa74  2  7iii7 9 clause       
7iii7-- 7,i7 by ins]t+ ( gr\nd ambulance
 s]vices or a provid] or suppli] ( air  
ambulance s]vices aft] may exempt a     
provid] or suppli]2 &  7,,ii7 by ins]t+ 
or provid] or suppli] ( air ambulance   
s]vices1 respectively1 aft] ability ( ! 
provid] or suppli] ( gr\nd ambulance    
s]vices2 &  7iv7 9 clause 7iv71 by      
ins]t+ or air ambulance s]vices aft]    
gr\nd ambulance s]vices2  7,b7 9        
subp>agraph 7,e7-- 7i7 9 clause 7ii7--  
7,i7 by /rik+ %all require & ins]t+     
%all--  7,i7 require  2  7,,ii7 by /rik+
 at ! end ! p]iod & ins]t+ 2 &2 &       
7,,iii7 by add+ at ! end ! foll[+ new   
subclause3  7,,ii7 require provid]s &   
suppli]s ( air ambulance s]vices to     
submit1 9 su* =m & mann] & at su* "t z  
specifi$ by ! ,secret>y 9 accordance )  

clause 7iii71 in=mation describ$ 9      
section #ajf7;a77#b7 ( ! ,no ,surprises 
,act = ye>s aft] ! la/ ,,nsa report+ ye>
 7z def9$ 9 clause 7iv77 z ! ,secret>y  
det]m9es appropriate1 b 9 no case less  
(t5 ?an once e #c ye>s4  2 &  7ii7 by   
add+ at ! end ! foll[+ new clauses3     
7iii7 ,application to air ambulance     
s]vices ,9 c>ry+ out clause 7ii77,,ii71 
! ,secret>y--  7,i7 may1 z ! ,secret>y  
det]m9es appropriate1 use ! data        
collection sy/em "u subp>agraph 7,a7 to 
provide = a s+le process = ! submission 
( in=mation "u ?is p>agraph1 includ+    
in=mation describ$ 9 su* clause )       
respect to provid]s & suppli]s ( air    
ambulance s]vices2 &  7,,ii7 %all1 to ! 
greate/ ext5t practicable1 align ! ye>s 
= :i* in=mation is requir$ to be        
submitt$ "u su* clause ) ! ye>s = :i*   
in=mation is requir$ to be submitt$ "u  
clause 7ii77,i74  7iv7 ,la/ ,,nsa       
report+ ye> ,= purposes ( clause        
7ii77,,ii71 ! t]m la/ ,,nsa report+ ye> 
means ! ye> ) respect to :i* in=mation  

is requir$ to be submitt$ "u section    
#ajf7;a77#a77;,b7 ( ! ,no ,surprises    
,act4  2 &  7,c7 9 subp>agraph 7,f77i71 
by /rik+ !reaft]11 su* & ins]t+ !reaft]1
 su*2 &  7#g7 by add+ at ! end ! foll[+3
  7#ah7 ,updat+ fee s*$ule to reflect   
mo/ rec5tly available data  7,a7        
,initial review & revisions  7i7 ,9     
g5]al ,to improve ! valuation ( gr\nd   
ambulance s]vices & air ambulance       
s]vices "u ?is subsection ! ,secret>y   
%all review ! relative value units1     
conv]sion factor1 air ambulance base    
rates1 & ! mileage rates appli$ "u ! fee
 s*$ule "u ?is subsection & %all1 by    
regulation & tak+ into acc\nt !         
in=mation requir$ "u subp>agraph 7,c71  
make su* adju/m5ts z are necess>y to    
ensure t su* relative value units1      
conv]sion factor1 base rates1 & mileage 
rates t are appli$ "u ! fee s*$ule =    
#bjbh ) respect to gr\nd ambulance      
s]vices & ) respect to air ambulance    
s]vices1 z applicable1 reflect ! co/s   
7includ+ labor-relat$ co/s & co/s relat$

 to uncomp5sat$ c>e71 exp5ses1 &        
res\rces us$ 9 furni%+ ! respective     
ambulance s]vice4  7ii7 ,updat$ paym5t  
am\nts def9$ ,= purposes ( ?is          
subsection1 ! t]m updat$ paym5t am\nts  
means ! paym5t am\nts det]m9$1 )        
application ( ! adju/m5ts pursuant to   
clause 7i71 "u ! fee s*$ule "u ?is      
subsection = #bjbh4  7,b7 ,ongo+ review 
& adju/m5ts  7i7 ,tri5nial review ,= ea*
 data-bas$ adju/m5t ye> 7z def9$ 9      
clause 7iv771 ) respect to gr\nd        
ambulance s]vices & ) respect to air    
ambulance s]vices1 ! ,secret>y %all     
review ! relative value units1 conv]sion
 factor1 air ambulance base rates1 & !  
mileage rates 7or any successor to or   
replacem5t = su* units1 factor1 or      
rates1 includ+ "u any paym5t me?odology 
develop$ pursuant to ?is subsection t is
 diff]5t f ! me?odology 9 effect z ( !  
date ( enactm5t ( ?is p>agraph71 z      
applicable to ! respective s]vices1     
e/abli%$ "u ! fee s*$ule "u ?is         
subsection4  7ii7 ,tri5nial adju/m5ts   

bas$ on updat$ factors & data ,= det]m9+
 paym5t am\nts "u ! fee s*$ule "u ?is   
subsection = gr\nd ambulance s]vices &  
air ambulance s]vices furni%$ dur+ a    
data-bas$ adju/m5t ye>1 ! ,secret>y     
%all1 bas$ on ! review "u clause 7i7 )  
respect to su* ye> & tak+ into acc\nt ! 
in=mation requir$ "u subp>agraph 7,c71  
by regulation adju/ ! numb] ( relative  
value units1 conv]sion factor1 air      
ambulance base rates1 mileage rates 7or 
any successor to or replacem5t = su*    
units1 factor1 or rates1 includ+ "u any 
paym5t me?odology develop$ pursuant to  
?is subsection t is diff]5t f !         
me?odology 9 effect z ( ! date (        
enactm5t ( ?is p>agraph71 or any        
comb9ation !re(1 z applicable to !      
respective s]vices1 to take into acc\nt 
*anges 9 m$ical practice1 *anges 9      
te*nology1 ! addition ( new s]vices1 new
 data on relative value compon5ts1 new  
co/ data 7includ+ on labor-relat$ co/s &
 co/s relat$ to uncomp5sat$ c>e71 & o!r 
relevant in=mation & factors4 ,!        

,secret>y %all publi% 9 ! ,f$]al ,regi/]
 an explanation ( ! basis = su*         
adju/m5ts made = a data-bas$ adju/m5t   
ye>4  7iii7 ,adju/m5ts = ye>s t are n   
data-bas$ adju/m5t ye>s ,beg9n+ ) #bjbi1
 ) respect to a ye> t is n a data-bas$  
adju/m5t ye>1 = det]m9+ ! paym5t am\nts 
"u ! fee s*$ule "u ?is subsection =     
gr\nd ambulance s]vices & air ambulance 
s]vices furni%$ dur+ su* ye>1 su* paym5t
 am\nts = su* s]vices furni%$ dur+ su*  
ye> %all be comput$ by increas+ ! paym5t
 am\nts det]m9$ "u ?is subsection = su* 
s]vices furni%$ dur+ ! previ\s ye> by ! 
p]c5tage increase 9 ! consum] price     
index = all urban consum]s 7,u4,s4 city 
av]age7 = ! #ab-mon? p]iod end+ ) ,june 
( ! previ\s ye>4  7iv7 ,data-bas$       
adju/m5t ye> def9$ ,= purposes ( ?is    
subp>agraph1 ! t]m data-bas$ adju/m5t   
ye> means #bjca & ea* ?ird ye> !reaft]4 
7,c7 ,use ( in=mation ,= purposes (     
subp>agraph 7,a7 & clauses 7i7 & 7ii7 ( 
subp>agraph 7,b71 ! ,secret>y %all use !
 mo/ rec5tly available data relat$ to   

gr\nd ambulance s]vices & air ambulance 
s]vices = :i* paym5t is made "u ! fee   
s*$ule "u ?is subsection1 includ+ 7z    
applicable to ! respective s]vices7     
in=mation collect$ or obta9$ pursuant to
 p>agraph 7#ag71 in=mation collect$ or  
obta9$ pursuant to section #ajf ( ! ,no 
,surprises ,act1 & su* o!r in=mation    
specifi$ by ! ,secret>y on co/s 7includ+
 labor-relat$ co/s & co/s relat$ to     
uncomp5sat$ c>e71 exp5ses1 & res\rces   
directly or indirectly relat$ to furni%+
 su* respective s]vices4 ,9 apply+ !    
previ\s s5t5ce ) respect to air         
ambulance s]vices1 9 ! case t in=mation 
collect$ or obta9$ pursuant to section  
#ajf ( ! ,no ,surprises ,act is n       
available1 ! ,secret>y %all in/ead use  
su* o!r comp>able in=mation 7z id5tifi$ 
by ! ,secret>y 9 consultation ) !       
organizations describ$ 9 p>agraph 7#d77 
on su* co/s1 exp5ses1 & res\rces relat$ 
to furni%+ air ambulance s]vices4  7#ai7
 ,/akehold] consultation = cont9u$      
assessm5t = modifications to improve fee

 s*$ule ,n lat] ?an ,decemb] #ca1 #bjbh1
 ! ,secret>y %all conv5e exp]ts &       
/akehold]s1 includ+ organizations       
describ$ 9 p>agraph 7#d71 to assess !   
fee s*$ule appli$ "u ?is subsection =   
gr\nd ambulance s]vices & = air         
ambulance s]vices & ! adequacy ( paym5ts
 = su* respective s]vices "u su* fee    
s*$ule & to submit1 n lat] ?an ,july #a1
 #bjbi1 to ! ,secret>y & ,congress      
recomm5dations = modifications to su*   
fee s*$ule1 includ+ ! paym5t me?odology 
"u ! fee s*$ule1 to improve ! valuation 
( su* respective s]vices "u ?is         
subsection4  4