State ground-ambulance balance billing protections: the gap federal law doesn't cover.
The federal No Surprises Act bans surprise medical bills for ER care, in-network-hospital out-of-network providers, and air ambulance — but it explicitly excludes ground ambulance. A typical ride is $500-$3,000 and a balance bill on top can be another $500-$2,000. About 15 states have stepped in with their own protections; the rest leave you exposed.
Why ground ambulance was excluded from NSA
Ground ambulance services are largely operated or regulated at the local and state level — not federally. Congress carved them out of NSA pending a federal Advisory Committee on Ground Ambulance and Patient Billing (GAPB), which has been studying the issue since 2022. As of 2026, no federal NSA expansion has passed, leaving state law as the only protection.
States with their own ground-ambulance balance-billing protections
Approximately 15 states (as of mid-2026) limit or ban balance billing for ground ambulance. The strongest protections, with effective dates:
- California — AB 716 (2024). Patients only owe in-network cost-sharing for ground ambulance services.
- Colorado — HB 19-1004 (2019). One of the first state laws on this.
- Florida — HB 387 (2020).
- Illinois — Network Adequacy and Transparency Act updates.
- Maine — LD 1095 (2020).
- Maryland — HB 1638 (2020).
- New Hampshire — SB 247 (2020).
- New Jersey — protections under the state's Out-of-Network Consumer Protection Act.
- New York — balance-billing protections for emergency ground ambulance through state insurance law.
- Ohio — HB 110 (2021).
- Vermont — statute regulating ambulance billing.
- Virginia — HB 1763 (2020).
- West Virginia — SB 268 (2022).
- Washington — HB 1688 (2022).
- Wisconsin — limited protections via state insurance regulation.
Each state's law varies in scope — some cover only emergency ground ambulance, some cover non-emergency transports too, some limit balance bills to a percentage above the negotiated rate rather than banning them outright. Check your specific state's Department of Insurance for current rules.
The other ~35 states: exposed
If you're billed for ground ambulance in a state without specific protections, your typical exposure:
- Insurer pays its "allowed amount" (often based on Medicare-rate × 100-200%).
- Ambulance service bills you the difference between its charge and the allowed amount — the balance bill.
- Some municipal/fire-district-operated services bill less aggressively; private services (AMR, Falck, others) often pursue the full balance.
What to do if you get a ground ambulance bill
- Don't pay immediately. Confirm what your insurer paid via the EOB. Pay the insurer-stated patient responsibility (deductible/coinsurance).
- Check your state. If you're in one of the 15 protection states, the balance bill above your in-network cost-sharing is likely illegal.
- Negotiate. Even in non-protection states, ground ambulance services often accept 50-70% of the balance bill in settlement, especially if you offer to pay it within 30 days.
- Apply for hardship/charity discount. Many ambulance services have written financial-hardship policies for patients below 200-400% of federal poverty level.
- File a state-insurance-commissioner complaint if you believe a balance bill violates your state's protections.
- Don't auto-let it go to collections. Medical debt under $500 was excluded from credit reports by the CFPB in 2024-2025; over $500 should still be disputed before paying or settling.
The federal direction
The federal Advisory Committee on Ground Ambulance and Patient Billing released recommendations in 2023 calling for NSA-style protections to be extended to ground ambulance, but no legislation has passed as of mid-2026. Watch cms.gov/nosurprises for updates.
Bottom line
Ground ambulance is the single biggest balance-billing gap in 2026. About 15 states have their own protections; the other 35 leave you exposed. If you receive an ambulance bill, check your state's status first — if you're in a protection state, the balance bill above your in-network cost-sharing is likely illegal and disputable. Even in non-protection states, negotiation and hardship programs often reduce the bill substantially. For the broader federal billing protections, see the No Surprises Act guide.
Reference information only — not legal advice. State balance-billing laws change frequently; verify current protections with your state's Department of Insurance before relying on this for a specific bill dispute. Last updated May 2026.