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Federal Register / Vol. 86, No. 177 / Thursday, September 16, 2021 / Proposed Rules
services as described in these proposed rules. However, HHS seeks comment on additional data sources that may inform the development of the report, and the extent to which such data sources could be used in lieu of collecting specific data elements.
In proposed 45 CFR 149.460b, HHS
proposes requiring submission of air ambulance base-level and transportlevel data on air ambulance services, as well as data elements not specifically identified in section 106a of the No Surprises Act, in order to collect the information necessary to satisfy these statutory requirements. For example, collection of data on revenue of the provider of air ambulance services from various sources, including non-transport sources, is necessary and appropriate to assess the competitiveness of the market for air ambulance services for purposes of the public report required under section 106c of the No Surprises Act, as well as to validate the data against the data collected from plans and issuers. Similarly, collection of air ambulance base-level data would help inform assessments regarding the competitiveness of the markets as well as capacity, service availability, and gaps in rural access to air ambulance services, which the Secretaries of HHS
and Transportation are required to assess under section 106c. Further, collection of transport-level data would enable the Secretaries of HHS and Transportation to conduct the assessments required under section 106c regarding the prices and services offered, the average charges for air ambulance services, and amounts paid by plans, issuers, and consumers, and would allow the Secretaries to complete the analyses of the debt collection practices, the frequency of patient balance billing, and the frequency of claims appeals.
Section 106a2 of the No Surprises Act requires providers of air ambulance services to submit data on the number and location of all air ambulance bases they operate, the number and type of aircraft they operate, and the number of transports disaggregated by payor mix.
In proposed 45 CFR 149.460b2, HHS
proposes collecting this information for each base, as well as additional information specific to the base and the aircraft that would enable the Secretaries of HHS and Transportation to conduct the assessments required in section 106c of the No Surprises Act.
This additional information would include the NPIs associated with the base, the number and type of staff, the number and type of air ambulance transports per aircraft including scene response patient transports, inter-

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facility patient transports, and transports of organs, medical personnel, and medical supplies, and the number of air ambulance responses for the base, including the number of such responses that did not result in transports. The additional information would also include the service delivery models of the base a hospital-owned or sponsored program, municipality-sponsored program, hospital independent partnership hybrid program, independent program, or tribally operated program in Alaska and whether the base shares operational costs with the affiliated or sponsor organizations, to complement and support the data required to be collected under section 9823b1B of the Code, section 723b1B of ERISA, section 2799A8b1B of the PHS Act, and section 106a2D of the No Surprises Act. The rationale for collecting this additional information is that service delivery models may vary by air ambulance base in addition to by provider. The additional information would also include base-specific data related to the providers of air ambulance services in-network contractual arrangements with plans and issuers as well as other, non-direct payor contracts with plans, issuers, or other entities including, but not limited to, TPAs or provider networks. This additional information would complement and support required data submissions and would also include air medical subscriptions or ambulance/
emergency medical service membership programs associated with the base, and whether the base operates ground ambulance services in addition to air ambulance services. Finally, collection of this additional information would enable analyses under various provisions of section 106c1 of the No Surprises Act.
Section 106a of the No Surprises Act requires providers of air ambulance services to submit cost data for air ambulance services, as HHS determines appropriate, and section 106a requires providers of air ambulance services to separate, to the maximum extent possible, air transportation costs and the costs of medical services and supplies.
HHS reviewed the ambulance cost reporting forms developed for the Medicare Ground Ambulance Data Collection System, ambulance cost reporting forms developed by states, a cost report study prepared for the Association of Air Medical Services and Members, a review of several studies on air ambulances services, consulted with the Secretary of Transportation and subject matter experts, and held
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listening sessions and additional conversations with providers of air ambulance services. Based on these activities, HHS determined that the service delivery or organizational model of a provider of air ambulance services, the designation of the service area of a base rural or urban,21 and the identification of fixed and variable costs are all important factors affecting the costs and revenues of providers of air ambulance services. Because these factors vary at the air ambulance base level, HHS proposes in 45 CFR
149.460b to require submission of detailed cost and revenue data at the air ambulance base level, as well as at the regional and corporate level, for each air ambulance base, if applicable. The data HHS proposes to collect would enable the separation of fixed and variable costs of providers of air ambulance services, as well as medical costs as opposed to air transportation costs.
HHS proposes in 45 CFR
149.460b3 that the required cost data be reported in the following categories:
Labor costs by type of staff; facility costs by facility including annual lease, rental, or mortgage costs, other costs of ownership, insurance, maintenance and improvements, utilities, taxes, computers and software, and other facility costs; vehicle costs by vehicle including vendor fees, depreciation, safety enhancements, non-medical equipment such as communications technology, registration and license, taxes, insurance, maintenance equipment and parts, fuel, and capital medical equipment; equipment and supplies; and overhead and vendor costs including insurance, training, billing, accounting and finance, human resources, travel, marketing, sales, dispatch or call center, IT support, legal, medical direction, fees, fines, and taxes.
HHS proposes in 45 CFR
149.460b4 that the required revenue data would include: Total revenue from paid air ambulance transports, by payor type, as well as revenue from other sources such as contracts with facilities such as hospitals, prisons, and nursing homes; revenue from emergency air medical services other than for transports for example, for transportation of organs, medical personnel, supplies, or equipment on an 21 HHS may apply a custom definition or a broadly accepted definition, such as the one used by CMS for the Medicare Ambulance Fee Schedule, to determine whether air ambulance bases and services are provided in rural or urban areas. More detail on the Medicare Ambulance Fee Schedule is available at: https www.cms.gov/medicare/
medicare-fee-for-service-payment/ambulancefee schedule.

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