The rule becomes effective April 22, 2014 and includes the following provisions: 

• Requires all helicopter air ambulance operations with medical personnel on board to be conducted under Part 135 operating rules, not just the flights involving actual transport of the patient. 
• Introduces new weather minimums and visibility requirements.
• Mandates flight planning of terrain and obstacles.
• Requires a pre-flight risk analysis focusing on characteristics of the planned flight path, flight crewmember availability to safely conduct the operation, weather, and if the flight has been rejected by another operator.
• Requires that all medical personnel be given a safety briefing with information specific to helicopter air ambulance flights prior to each flight or receive eight hours of helicopter safety training every two years.
• Mandates that operators with 10 or more helicopter air ambulances establish operations control centers staffed with operations control specialists.
• Requires all helicopter air ambulances be equipped with both helicopter terrain awareness and warning systems by April 22, 2017 and flight data monitoring systems by April 22, 2018.
• Mandates that all helicopter air ambulance pilots hold instrument ratings and demonstrate the ability to recover from inadvertent flight into instrument meteorological conditions.

The rule does not apply to public aircraft unless it operating for a commercial purpose.  This means public agencies who are not paid for their services are not bound by the new rule.