Ground Ambulances: The Last Gap in the No Surprises Act

Katie Moraida was just feet from the hospital when her baby decided it was time. Sitting in the front seat of her car, she gave birth as her husband pulled over in a panic. “She went like this, pop, he came shooting out,” her husband recalled. Paramedics soon arrived to carry Moraida and her newborn son the final few feet to the emergency department, an ambulance ride that lasted “not even a full minute.” For that service, the ambulance provider billed the new family $3,500.

Moraida’s insurer covered only part of the bill, leaving the family responsible for the remainder. This type of “surprise” billing is common in the United States, where patients often have little say in whether the medical services they receive are provided by in-network providers or are otherwise on the hook for disagreements between their insurer and the provider.

Surprise bills are especially common for ambulance rides. Because ambulances are dispatched randomly, nearly 80 percent of rides result in out-of-network bills. The average surprise bill is $450, but, as the Moraidas discovered, can easily reach into the thousands. 

Stories like the Moraidas’ have spurred a flurry of legislation since 2020. Many states agree that ambulance bills should be capped at a “reasonable” rate but differ on who gets to decide what that rate is.

Of the states that have passed or proposed legislation in the past decade, the majority have chosen to anchor “reasonable” payments to a percentage of Medicare’s reimbursement rates. This uniform solution is striking, given how localized ambulance needs are. As states refine their policies in this new policy space, the most promising reforms will be those that account for the unique challenges facing local ambulance providers rather than those that import Medicare’s generic reimbursement scheme.

Ground Ambulances Left Behind

Between 2017 and 2019, one in five adults received a surprise out-of-network bill despite being insured. In response, Congress passed the No Surprises Act of 2022 to protect patients from surprise medical bills for (1) emergency care, (2) non-emergent care from out-of-network providers at in-network facilities, and (3) air ambulance services. Patients hailed the law as a “real victory.”

The Act banned “balance billing,” where providers send patients the portion of a bill that insurers refuse to cover. Although it is not clear if the law has lowered the overall size of medical bills, it provides real relief to patients who would have otherwise been stuck with massive out-of-network charges. The Act continues to enjoy strong supportamong voters.

But ground ambulances were notably excluded from the Act. Although the law extended its protections to air ambulance services, Congress directed the Secretary of Health and Human Services to convene an advisory committeeto study the issue of ground ambulance coverage.

That reluctance reflects the difficulty of regulating ambulance services. Unlike emergency departments, which are comparatively uniform in function and funding, ambulances are run by a patchwork of fire departments, municipalities, hospitals, and private operators. Their funding ranges from local tax dollars to private equity investment.

These arrangements vary widely. In Massachusetts, half of all ambulance rides are provided by private companies; across the border in New Hampshire, only 19 percent are. Rural and urban providers face different challenges requiring different funding schemes as well: Rural ambulances travel farther and make fewer trips, meaning they struggle to spread costs across calls. Faced with such variation, Congress found it difficult to craft a federal solution.

States Step In

Even before the No Surprises Act left ground ambulances in the regulatory wilderness, states had begun stepping in. New York led the way in 2015, becoming the first to prohibit out-of-network balance billing for emergency ambulance services. Its law limits payments to “usual and customary charges” as determined by the insurer, though providers can challenge those decisions before the New York State Department of Financial Services. 

Subsequent state laws can be roughly grouped into three categories, each reserving a different level of decision-making authority to the state. Some, like Ohio, follow New York’s model and entrust insurers with setting a “reasonable” rate for out-of-network rides. California goes a step further, requiring that insurers determine this value using “statistically credible information” such as the specific services provided and the qualifications of the dispatched paramedics.

A second group places responsibility in the hands of state agencies. Utah directs its Bureau of Emergency Medical Services to set “just and reasonable” rates, while Arkansas relies on a fee schedule determined by its Workers’ Compensation Commission.

The most common approach, however, has been to anchor rates directly to Medicare’s ambulance fee schedule, which has two components: a base payment that varies by geography and intensity of care, and a mileage payment. Recent and representative examples are Louisiana, which caps its payments at 325 percent of what Medicare would pay for the same service, and West Virginia, which is considering a cap at 400 percent. These uniform bills have faced mixed legislative success.

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This uniform approach is surprising given the local nature of ambulance needs. If Medicare’s two-part formula were adequate, Congress presumably would have adopted it instead of punting the issue to HHS for more study. Multiplying this formula by 325, 350, or 400 percent does not make it a state-specific solution.

Some states, however, have taken a closer look at their own needs. Maine, for example, recognized that its rural geography meant that many calls ended with treatment at home. Because insurers typically reimburse only for calls resulting in transport to a hospital, those “treat-no-transport” calls went unpaid, frustrating providers. To address this, Maine became the first state to reimburse ambulance providers for such calls. New Hampshire followed suit in 2025.

As states like Colorado, Florida, and Mississippi reflect on their failed Medicare-based proposals, they should feel bold in their next iteration, moving beyond uniform caps to schemes responsive to local needs. Experimentation is healthy, and even failed bills lay the groundwork for more durable solutions in the future.