Surprise Ambulance Bills - The $100 Cap Congress Never Passed
You can shop for a surgeon. You can shop for an MRI.
You cannot shop for an ambulance.
And that one difference is why a surprise ambulance bill is still legal in most of the country in 2026 — even after Congress passed a law specifically designed to end surprise medical bills.
Here's the part that catches almost everyone off guard. The No Surprises Act does protect you from a surprise air ambulance bill. A helicopter. The most expensive ride in American medicine.
It does not protect you from the ambulance that drives you three miles down the road.
That's not a loophole someone found later. It's how the law was written.
Does the No Surprises Act cover ambulances?
Air ambulances, yes. Ground ambulances, no. That's the whole answer, and it's not a gray area.
The No Surprises Act was enacted as Division BB, Title I of the Consolidated Appropriations Act, 2021 (Public Law 116-260, signed December 27, 2020) and took effect January 1, 2022. It bans balance billing for emergency services, for out-of-network clinicians working at in-network facilities, and for air ambulances.
Ground ambulances were carved out.
healthinsurance.org, in a glossary entry updated through August 2, 2026, puts it about as plainly as it can be put: "Ground ambulance providers, which are a significant source of surprise balance billing, are not regulated under the No Surprises Act."
So if a medical helicopter transports you, you owe your in-network cost-sharing and nothing more. If an ambulance takes you to the same hospital by road, you can be balance billed for whatever your insurer didn't cover.
Same emergency. Same law. Opposite outcome.
So why did Congress leave ground ambulances out?
Because ground EMS is structurally messy, and lawmakers decided it was too complicated to regulate in one pass.
Health policy experts quoted in 2026 reporting describe ground ambulance service as "a patchwork of municipal governments, fire departments, hospitals, nonprofit organizations and private companies." A 2026 PublicSource piece said it more bluntly: Congress didn't include ground ambulances "because they found the emergency transportation too complex to regulate."
The numbers back that up. According to Peterson-KFF's analysis of 2020 NEMSIS data, fire departments provide 37% of emergency ground ambulance rides and other government agencies another 25% — roughly 62% government-run. Private non-hospital companies account for 30%, hospital-owned ambulances 8%.
출처 · KFF / Peterson-KFF Health System Tracker, “Ground ambulance rides and potential for surprise billing”
healthsystemtracker.org
Regulating a fire department's billing practices is a genuinely different legal problem than regulating an anesthesiology group. That's the honest reason the carve-out survived.
It's an explanation. It is not much comfort when the bill arrives.
What happened to the $100 cap Congress was handed?
A federal advisory committee recommended capping your share of a ground ambulance bill at the lesser of $100 or 10% of the total. Congress has not acted on it.
This is the part of the story most coverage skips, and it's the part that should make you angriest.
Instead of protecting patients directly, Section 117(a) of the No Surprises Act directed the Secretaries of Labor, Treasury and HHS to convene an advisory committee — the Advisory Committee on Ground Ambulance and Patient Billing (GAPB). Its assignment, written into the statute, was to review options to improve disclosure of ambulance charges and "protect consumers from balance billing," including "legislative options for Congress."
출처 · Federal Register Vol. 88 No. 145 — Ground Ambulance and Patient Billing Advisory Committee (primary federal document) / CMS committee page
govinfo.gov (PDF)
The committee had 17 members. Worth noting who was in the room: federal agency designees, a DOT/NHTSA representative, state insurance regulators, health insurers, consumer and patient advocates, state and local government officials, emergency physicians, EMS officials, EMTs and paramedics, three ground ambulance industry representatives, and two at-large members. Industry, insurers, and consumer advocates sat at the same table — which shapes how consensus recommendations come out.
Its Report to the Secretaries is dated March 29, 2024 and was publicly issued August 28, 2024. Six main recommendations:
- Tailored legislation modeled on the No Surprises Act but customized for ground EMS
- Standardized definitions for terms like "community paramedicine" and "cost"
- A requirement that health plans cover emergency ground ambulance service regardless of network status
- A permanent federal advisory committee
- A balance billing prohibition with a patient cost-sharing cap
- Billing transparency and timely-payment rules, with enforcement
The number to remember is in recommendation 5: patients would pay the lesser of $100 or 10% of the total ambulance bill, and that amount would count toward their in-network deductible.
On payment rates, the committee deliberately did not name a single national multiple of Medicare. It recommended state or local regulated rates with federal guardrails, plus a 30-day deadline for insurers to pay or deny, with penalties for delay.
So the homework got done. A committee Congress itself created delivered a specific, workable answer.
And then nothing happened.
As of 2026, the Commonwealth Fund reports Congress "has not shown interest in taking up this issue," and that "in the absence of federal action, responsibility will remain with the states." PublicSource, writing in July 2026, noted that nearly four years after the committee was convened, "no meaningful action has been taken."
How much does an ambulance ride cost?
Roughly $1,000 to $1,400 in billed charges for a typical ride, but what you actually owe depends entirely on your plan, your state, and whether the provider is in network. There is no single national price, and anyone who gives you one is simplifying.
Here are the better-anchored figures, with sources attached so you can judge them yourself.
FAIR Health — an independent nonprofit that maintains a large claims database, originally established under a New York Attorney General settlement — reported average charges for advanced life support (ALS) emergency ground ambulance rising from $1,042 in 2017 to $1,277 in 2020. Basic life support (BLS) emergency charges rose from $800 to $940 over the same period.
출처 · FAIR Health, “Nearly 60 Percent of Ground Ambulance Rides Were Out of Network in 2022” — independent nonprofit claims database
fairhealth.org
GoodRx, in 2026, put the national average base rate for an ALS transport at $1,379, with an average out-of-pocket cost of about $450 for insured patients. Treat that as secondary consumer media rather than a primary dataset.
A quick caution, because you'll run into these two numbers everywhere: $1,046 and $1,536 are widely circulated as "CMS averages." They appear to originate from Health Bill Central, a commercial medical-bill-negotiation site, presenting its own reading of Medicare claims data — specifically "average submitted charge," which is a list price. Those figures are plausible, but they are not an official CMS publication, and they come from a company whose business model depends on you believing ambulance bills are inflated.
The mileage rate that varies 5x by state
This is the number that surprised me most in the data. FAIR Health's 2022 analysis found the average allowed amount per statute mile ranged from $28.35 in Utah, $24.29 in Wyoming and $20.63 in California down to $5.79 in Florida, $7.55 in Maine and $7.66 in North Carolina.
Nearly a five-fold spread for the same mile of road, depending on which state line you're on.
What Medicare pays, and why it matters even if you're not on Medicare
Medicare Part B covers medically necessary ambulance transport at 80% of the Medicare-approved amount, leaving you a 20% coinsurance after the Part B deductible ($283 in 2026). Coverage applies only to transport to the nearest appropriate facility capable of providing the care you need — ask to be taken somewhere farther and Medicare pays what it would have paid to the nearest facility, and you owe the difference. Ambulance suppliers must accept the Medicare-approved amount as payment in full for covered services.
That matters for everyone, not just Medicare beneficiaries, because Medicare pays far below billed charges. When states write ambulance balance-billing laws, they typically peg out-of-network payment to a multiple of the Medicare rate. That's the benchmark the whole fight is built on.
And the air ambulance, for scale
The most authoritative U.S. government figure is from GAO in 2017: a national median price charged of about $36,400 for rotary-wing (helicopter) and $40,600 for fixed-wing transports. That's now several years old, and it's worth dating it when you see it quoted.
The commonly repeated "$27,000 to $80,000" range comes from consumer media and industry sources — including air-medical membership programs that sell subscriptions — not from a government statistic.
The irony is hard to miss: the most expensive ride is the one Congress actually protected you from.
How often does this actually happen?
Depending on the dataset, somewhere between roughly half and four in five ground ambulance rides have historically carried out-of-network charges. The honest answer is a range, not a number, and here's why.
| Study | Finding | Data year | What it counted |
|---|---|---|---|
| Peterson-KFF (June 2021) | 51% of emergency rides, 39% of non-emergency | 2018 MarketScan claims | Rides with at least one out-of-network charge |
| Health Affairs, Chhabra et al. (April 2020) | 79% of ground rides, 71% of all ambulance rides | 2013–2017, one large insurer | Rides that could result in an out-of-network bill |
| JAMA Internal Medicine (2019) | 86% of rides to emergency departments | — | Privately insured patients |
| FAIR Health (September 2023) | 59.4% of ground claim lines, 62.0% for emergency | 2022 | Claim lines, not rides |
They differ because they use different claims databases, different years, and different units of analysis (rides versus claim lines). The trend across all of them is that out-of-network rates are high but slowly declining as more states legislate.
One important label on the most-quoted statistic. The line you've probably seen — "half of ambulance rides lead to surprise bills" — is a research estimate of exposure, not a government count of bills actually mailed. It comes from a KFF/Peterson analysis of insurance claims. Same with the widely repeated $450 median surprise bill: that's a median potential balance bill from a 2020 peer-reviewed study of 2013–17 claims, and it's several years old now. (One 2026 article attributed the $450 figure to a Harvard center; the number actually traces back to the Health Affairs study.)
For scale, Peterson-KFF also found that about 3 million privately insured people arrive at emergency rooms by ambulance each year. And in seven states — Washington, California, Florida, Colorado, Texas, Illinois and Wisconsin — more than two-thirds of emergency rides carried an out-of-network charge.
출처 · Washington State Office of the Insurance Commissioner — new billing protections for ground ambulance patients (state regulator)
insurance.wa.gov
Which states protect against ambulance billing?
Roughly 22 to 24 states, depending on how you count partial protections. I'm giving you the range on purpose, because the sources genuinely disagree, and I'd rather tell you that than pretend there's a clean number.
- The Commonwealth Fund in 2026 counts 22 states with ground ambulance balance-billing protection for people in fully insured plans, with five added in 2025 alone: North Dakota, Utah, New Hampshire, Oregon and West Virginia.
- healthinsurance.org, updated August 2, 2026, counts 23 states and publishes a list.
- The Commonwealth Fund's own interactive map has been described as showing 24, depending on how partial protections are counted.
The counts differ over whether you include states with partial protection and whether you count laws that haven't taken effect yet.
Here's the 23-state list from healthinsurance.org, as of August 2, 2026:
Alabama, Arkansas, California, Colorado, Delaware, Florida, Illinois, Indiana, Louisiana, Maine, Maryland, Mississippi, New Hampshire, New York, North Dakota, Ohio, Oklahoma, Oregon, Texas, Utah, Vermont, Washington and West Virginia.
Whichever count you prefer, the direction is unmistakable. CMS listed only 10 states with ground ambulance billing protections as of November 15, 2021 — Colorado, Delaware, Florida, Illinois, Maine, Maryland, New York, Ohio, Vermont and West Virginia. Going from 10 to around 23 in five years is real movement, and it happened entirely at the state level while Congress sat on the committee report.
Being on the list doesn't mean you're fully protected
Three things to check before you relax:
The protections aren't equivalent. Colorado and Maryland protect against surprise balance billing only for private ambulance services — a large carve-out, since most U.S. ground ambulance service is publicly operated. West Virginia's current protections apply only to HMOs; broader protections for non-HMO plans take effect in 2027.
Three states worth naming concretely, because their rules are specific enough to use:
- Washington expanded its Balance Billing Protection Act to ground ambulances effective December 31, 2024 (HB 5986, 2023). It bans balance billing for both emergency and non-emergency ground transport. Payment is set at the rate established by the local jurisdiction that operates or contracts for the service; where no local rate exists, the provider gets the lesser of 325% of the Medicare rate or the billed charge. Out-of-network providers must bill the health plan directly and cannot ask you to waive your protections. Complaints go to the Office of the Insurance Commissioner at 360-725-7055.
- New Hampshire: SB 245, codified at RSA 420-J:21, effective January 1, 2026. Standardized reimbursement for ground ambulance services for fully insured members, and a balance billing prohibition for covered services.
- Oregon: HB 3243 (2025), effective January 1, 2026. Protects policyholders from balance billing by Ground Ambulance Service Organizations, with rate-reporting overseen by the Division of Financial Regulation.
And the trap almost nobody mentions. State insurance laws do not reach self-funded (self-insured) employer plans, which are governed by ERISA — and self-funding covers the majority of U.S. workers with employer coverage.
Read that again if you skimmed it. You can live in a "protected" state, have good insurance through your job, and still get a balance bill, because your employer self-funds the plan and state law simply doesn't apply.
Before you assume you're covered: check your plan documents or the back of your insurance card for whether the plan is self-funded. Your HR benefits contact can tell you in about thirty seconds.
What can I do about an ambulance bill?
Work through these six steps in order. Nobody can promise you a zero balance, but each step has produced real reductions for real people, and the whole sequence costs you nothing but time.
Step 1 - Find out whether any protection applies
- Determine your plan type: fully insured (state law may protect you) versus self-funded (state law generally does not).
- Check whether your state is on the protected list, and whether the protection is partial — private-ambulance-only, HMO-only, emergency-only.
- Where to check: your state Department of Insurance or Insurance Commissioner website. That's the agency that enforces these laws and takes complaints. (Washington's OIC: 360-725-7055. Pennsylvania Insurance Department consumer hotline: 1-877-881-6388.)
- Federal help desk: the No Surprises Help Desk, 1-800-985-3059, 8am–8pm ET, seven days a week. Useful for air ambulance and other bills covered by the federal ban — remember that ground ambulance sits outside it.
Step 2 - Get the documents before you argue about anything
Request an itemized bill and the Patient Care Report (PCR) from the ambulance provider, then compare them against each other.
Three things to look for:
- ALS billed when the PCR shows no ALS interventions — no IV access, no cardiac monitoring. An ALS-to-BLS correction is one of the single largest reductions available. (This tip circulates mainly through bill-negotiation companies, which have a commercial interest in it, but the underlying logic — the billing level has to match the documented care — is sound.)
- Mileage. Only loaded miles, with the patient on board, should be billed. Check the distance yourself.
- Your Explanation of Benefits (EOB) from the insurer, to see what was allowed versus what was billed.
Step 3 - Appeal to the insurer
Both the insurer and the ambulance provider typically have an appeals process, and filing one is often what surfaces a coding error in the first place. For insurer-side disputes you generally have 180 days to file an internal appeal.
Ask the insurer specifically to reprocess the claim at the in-network rate — and say plainly that you had no ability to choose the provider. That's the strongest argument you have, because it happens to be true.
If the insurer upholds the denial, request external review through your state's process.
Step 4 - Negotiate with the provider
CMS's own consumer guidance notes that providers or their billing departments "can sometimes lower the price and may also offer payment plans."
Municipal and fire-department EMS agencies often have hardship or financial assistance policies and may write off the balance. Ask explicitly for the financial assistance or charity care policy, in writing.
One honest caveat: the hospital charity care obligations under IRS §501(r) apply to nonprofit hospitals, not to municipal or private ambulance services. Ambulance financial assistance is discretionary and varies by agency. It's absolutely worth asking. It is not guaranteed to exist.
Step 5 - Escalate
File with your state insurance regulator, and where the provider's own conduct is the issue, your state attorney general. Some states also run Consumer Assistance Programs that will advise on your specific case.
Escalation works more often than people expect, partly because it creates a paper trail somebody has to answer. In the Tennessee case below, the bill was forgiven only after a TV station started making calls.
Step 6 - Prevent the next one, where you can
- For non-emergency transports — hospital-to-hospital transfers, discharge to a skilled nursing facility — you often can ask in advance. Call your insurer and ask which ambulance companies are in network. This is where that 39% non-emergency out-of-network rate is genuinely avoidable.
- Some fire and EMS agencies sell annual membership or subscription programs (historically roughly $30–$75 a year) that waive out-of-pocket costs for their own service. Read the fine print: these cover only that agency's transports, and they're sold by the agency itself.
- If you're on Medicare, remember the nearest appropriate facility rule. Requesting a hospital farther away shifts the extra cost onto you.
The $4,800 bill that passed the House 94-0 and died anyway
If you want to understand why this hasn't been fixed, Tennessee in 2026 is the whole story in miniature.
Joshua Carlson of Clarksville was billed $4,800 for a 49-mile emergency transfer to Vanderbilt University Medical Center. His insurer paid about $1,000. He was left owing more than twice what his surgery cost.
House Bill 1061, sponsored by Rep. Greg Vital (R-Harrison), would have prohibited out-of-network ground ambulance balance billing for insured patients in emergencies. It passed the Tennessee House unanimously, 94–0 — and then stalled in the Senate Commerce and Labor Committee before adjournment. Vital pledged to reintroduce it.
Carlson's bill was ultimately forgiven, but only after a TV station made inquiries.
Vital's own framing of the problem is the cleanest sentence anyone has written about it:
"When you call 911, your focus should be on getting the critical help you need, not worrying about whether the ambulance is in-network."
A bill that gets 94 votes and zero opposition in one chamber is not controversial. It still didn't become law.
Honestly, the other side has a real argument
I don't want to hand you a story with an obvious villain, because the data doesn't support one.
Rural EMS economics are genuinely brutal. Rural ambulances travel farther and run fewer calls, so fixed costs can't be spread across volume — which produces much higher operating costs per transport, according to University of Southern Maine research cited by PublicSource. When hospitals close, transport distances get longer, raising both cost and patient risk.
This isn't theoretical. Southwest EMS ceased operations in Greene County, Pennsylvania, in 2024 for financial reasons.
That's the industry's core argument against rate caps: set payment too low and services shut down, and an ambulance that doesn't come is a worse outcome than an ambulance that bills too much.
For balance in the other direction: roughly 10% of ambulance providers are owned by private equity firms, per a RAND-cited analysis. Not every operator in this market is a volunteer fire department.
Which is roughly why the GAPB committee recommended state or local regulated rates with federal guardrails rather than one national number. It's the harder answer. It's also probably the right one.
A note on who's telling you what
Because this is a topic where almost every source has a stake, here's the scorecard:
- U.S. PIRG Education Fund — a nonprofit consumer advocacy organization. Its research is transparent and widely cited, but it is actively campaigning for federal legislation.
- American Ambulance Association — the ground ambulance industry trade association. Its state balance-billing overview sells for $1,000 to non-members. Useful for understanding industry positions; an interested party opposing low payment caps.
- FAIR Health — an independent nonprofit claims database, generally treated as neutral, though its data covers commercially insured claims only.
- Bill-negotiation companies (Health Bill Central, CareRoute, BillRazor and similar) — their tactical advice is often genuinely useful; their statistics shouldn't be your primary citation, because they profit from you believing bills are inflated.
- Insurers — interested parties on the payer side; they favor rate benchmarks tied to Medicare.
- Government and neutral sources worth leading with: CMS, the Federal Register, GAO, Peterson-KFF, Health Affairs, and your state insurance department.
FAQ
Q. Does the No Surprises Act cover ambulance rides?
A. It covers air ambulances but not ground ambulances. Ground ambulance services were excluded when the law was enacted in 2020, and they remain outside the federal balance billing ban as of 2026.
Q. Why is my ambulance bill so high if I have insurance?
A. Most likely because the ambulance was out of network. Depending on the dataset, between roughly half and four in five ground ambulance rides have historically involved out-of-network charges, and outside a protected state your insurer only has to pay its allowed amount — the provider can bill you the rest.
Q. Do I have to pay a surprise ambulance bill?
A. It depends on your state and your plan type. If you're in a fully insured plan in a state with ground ambulance protections, balance billing may be prohibited. If your employer plan is self-funded, state law generally doesn't apply. Either way, request an itemized bill and the Patient Care Report before paying anything.
Q. Can you negotiate an ambulance bill?
A. Often, yes. CMS's own guidance notes that providers can sometimes lower the price and may offer payment plans, and many municipal and fire-department EMS agencies have hardship policies. Ask for the financial assistance policy in writing.
Q. Which states protect against surprise ambulance bills in 2026?
A. Roughly 22 to 24, depending on how partial protections are counted. healthinsurance.org's August 2026 list includes Alabama, Arkansas, California, Colorado, Delaware, Florida, Illinois, Indiana, Louisiana, Maine, Maryland, Mississippi, New Hampshire, New York, North Dakota, Ohio, Oklahoma, Oregon, Texas, Utah, Vermont, Washington and West Virginia.
Q. Does state ambulance billing protection apply to my employer plan?
A. Not if the plan is self-funded. Self-funded employer plans are governed by ERISA and are not subject to state insurance law — and self-funding covers most U.S. workers with employer coverage. Check your plan documents.
Q. How much does an ambulance ride cost without insurance?
A. There's no single national price. FAIR Health reported average charges of $1,277 for ALS emergency transport and $940 for BLS emergency transport in 2020; GoodRx put the 2026 national average ALS base rate at $1,379. Mileage charges vary roughly five-fold between states.
Do this one thing tonight
You're not going to memorize your state's balance billing statute, and you shouldn't have to.
So do the one thing that actually changes your outcome: find out whether your health plan is fully insured or self-funded.
That single fact determines whether any state ambulance protection applies to you at all. It's in your plan documents, and your HR benefits contact can answer it in one email. Five minutes, once, and you'll know where you stand before the ambulance shows up rather than six weeks after.
Then, if a bill does arrive: itemized bill and Patient Care Report first. Argue second.
Have you gotten one of these bills? I'd genuinely like to know how it went — how much, what state, and whether appealing moved the number at all. That's the kind of thing this data can't tell you and readers can.
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