The PEAKS Act amends title XVIII of the Social Security Act to update the Medicare ambulance fee schedule for Critical Access Hospitals (CAHs). It adds a 15-mile drive exception to the existing 35-mile rule for mountainous terrain or areas with only secondary roads.
The bill also creates a distance-based designation pathway: beginning January 1, 2026, hospitals that previously met the CAH distance standard and are located within a 10- to 15-mile band from a CAH can be treated as meeting the distance requirement, and it directs the Secretary to issue regulations within one year to implement these changes. Taken together, the changes are intended to preserve emergency access in rural, hard-to-reach areas by modulating CAH designation and reimbursement language around distance.
At a Glance
What It Does
Amends Section 1834(l)(8) to insert a 15-mile drive allowance after the 35-mile drive for ambulance services when mountainous terrain or roads are limited. Adds a new subsection to designate hospitals that meet certain distance criteria as CAHs for purposes of the program.
Who It Affects
Critical Access Hospitals and ambulance providers serving rural or mountainous regions; CMS and other federal payors; patients who rely on ambulance services in remote areas.
Why It Matters
By adjusting the distance framework, the bill aims to safeguard emergency access where terrain and road networks complicate travel, potentially preserving CAH status and related reimbursements in underserved regions.
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What This Bill Actually Does
The PEAKS Act makes targeted changes to how ambulance services at Critical Access Hospitals are reimbursed under Medicare. It fuses a terrain-based distance adjustment into the existing 35-mile rule by explicitly allowing a 15-mile drive distance when mountainous terrain or areas with only secondary roads are present.
This recognizes the practical constraints faced by ambulance providers in rugged rural settings and extends the reach of CAH reimbursements in such areas.
In addition, the bill adds a new eligibility pathway for CAH designation related to distance. Starting January 1, 2026, hospitals that previously met the 15-mile distance benchmark for mountainous or secondary-road terrain will be deemed to meet the CAH distance requirement if a nearby hospital (or other facility) located 10 to 15 miles away exists and meets the subsection’s criteria.
This is intended to maintain emergency access networks where hospital footprints are sparse and geography creates genuine access barriers. The Secretary would also promulgate regulations within one year of enactment to operationalize these changes.Overall, the PEAKS Act focuses on preserving emergency access in remote areas by recalibrating distance-based eligibility for reimbursement and designation.
Practically, this could affect where a hospital can qualify as a CAH and how ambulance services are priced for remote patient transport, with implementation details to be set out in forthcoming regulations.
The Five Things You Need to Know
The bill amends Section 1834(l)(8) to insert a 15-mile drive exception for mountainous terrain or areas with only secondary roads after the 35-mile drive language.
Beginning January 1, 2026, hospitals that previously met the 15-mile distance benchmark can be deemed to meet the CAH distance requirement if a nearby facility is located 10–15 miles away.
The Secretary must issue regulations to carry out these changes within one year of enactment.
The changes affect Medicare ambulance service reimbursements and CAH designation criteria in rural, hard-to-reach areas.
The bill explicitly targets preserving emergency access by adapting distance calculations to terrain and road availability.
Section-by-Section Breakdown
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Short title
This act may be cited as the Preserving Emergency Access in Key Sites Act (PEAKS Act). The short title signals the bill’s focus on maintaining rapid emergency access in rural or challenging geographies by tweaking ambulance reimbursement rules and CAH designation standards.
Update to fee schedule for ambulance services provided by CAHs
The bill amends the Medicare ambulance fee schedule by inserting a 15-mile drive allowance in mountainous terrain or areas with only secondary roads, immediately after the existing 35-mile drive threshold. This creates a practical exception to distance calculations when terrain or road conditions constrain patient transport, and it aligns reimbursement logic with real-world rural access scenarios.
Treatment of hospitals that met mountainous terrain or secondary roads distance requirements for designation
Beginning January 1, 2026, if a hospital described in this section was designated as a CAH and demonstrates the relevant 15-mile distance criteria as of its last CAH certification, it shall be deemed to meet the 15-mile distance requirement under subsection (c)(2)(B)(i)(I). If after enactment a new hospital or facility is placed within 10 to 15 miles of the hospital, designation considerations are adjusted to reflect this proximity. The Secretary is required to promulgate regulations within one year to implement these provisions, establishing how distance-based deeming interacts with CAH designation and any accompanying administrative processes.
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Explore Healthcare in Codify Search →Who Benefits and Who Bears the Cost
Every bill creates winners and losers. Here's who stands to gain and who bears the cost.
Who Benefits
- Rural Critical Access Hospitals serving mountainous or isolated communities gain greater assurance of CAH designation and reimbursement eligibility when realistic travel distances are constrained by terrain.
- Ambulance service providers operating in hard-to-reach geographies benefit from regulatory alignment that reflects actual transport conditions and possible reimbursement pathways.
- Medicare beneficiaries in remote regions gain improved emergency transport coverage when distance metrics better reflect service realities.
- State health departments and rural health networks may see more stable emergency access planning due to clearer designation criteria.
- CMS and federal program administrators gain a framework for consistent reimbursement in sparsely populated, terrain-challenged districts.
Who Bears the Cost
- Hospitals outside the 10–15 mile proximity window that do not meet the amended distance criteria may experience unchanged or reduced eligibility for CAH designation as aligned with the new interpretation.
- Some CAHs could experience budgetary or administrative shifts as designation and reimbursement calculations adapt to the new distance framework.
- Regulatory agencies will incur costs and workload to develop and enforce the new regulations within the one-year timeline.
- Rural EMS providers may incur transitional costs associated with adjusting to updated reimbursement rules and reporting requirements.
Key Issues
The Core Tension
The central dilemma is balancing expanded access with fiscal sustainability and designation integrity: broadening the distance interpretation could preserve service continuity in remote areas but risks diluting CAH criteria or shifting costs in ways that require careful oversight.
The PEAKS Act introduces a nuanced shift in how distance is measured for ambulance staffing and CAH designation in terrain-challenged regions. While the goal is to preserve access, the amendments may reclassify which hospitals qualify as CAHs and how much they are reimbursed for ambulance services.
The regulatory timetable—final rules within one year—leaves some implementation questions unresolved, including how to verify last CAH certifications and how to handle edge cases where new facilities lie within the 10–15 mile band but do not share other CAH criteria. Potential budgetary impacts depend on how many hospitals are deemed eligible under the tweaked distance framework and how reimbursements are adjusted in rural markets.
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