Ground ambulance billing and the No Surprises Act

What the federal law leaves out

The No Surprises Act covers emergency services, non-emergency care by out-of-network clinicians at in-network facilities, and air ambulance. Congress left ground ambulance out and instead created the Advisory Committee on Ground Ambulance and Patient Billing (GAPB), which approved recommendations in fall 2023 and issued them in 2024. Federal follow-through has stalled; as of 2026 no federal ground ambulance balance-billing protection has been enacted.

The scale of the gap

• About 3 million privately insured people use emergency ground ambulance transport each year.
• More than one in four of those trips may produce a surprise bill.
• The average commercial ground ambulance bill was $1,093 in 2021.

States are filling it

Georgetown's Center on Health Insurance Reforms counts 22 states with some ground ambulance protection; the Commonwealth Fund's map lists 24 for fully insured plans. New Hampshire is among the newest: its prohibition took effect January 1, 2026 and covers both emergency and non-emergency transports under state-regulated plans. State laws vary on payment standards, which providers they cover, and whether non-emergency transports are included.

What it means for an ambulance operator

• Split the payer book by plan funding status. State rules reach fully insured and other state-regulated plans; self-funded ERISA plans generally fall outside them.
• Model by date of service. New state laws apply from their effective dates, so the same payer can sit under two regimes in one year.
• No federal IDR backstop. Underpaid ground claims outside a state law are a plan-appeal and contract problem, not an IDR filing.
• Air medical is different. If you also fly, those transports are fully inside the federal process — see air ambulance IDR.

Where we fit

We file federal IDR, so we do not file ground ambulance disputes that the law excludes. For mixed air and ground operators, or hospital-based groups that also run transport, we screen the full out-of-network book and separate what is federally disputable from what isn't.

FAQ

Does the No Surprises Act cover ground ambulances?

No. Ground ambulance services are excluded from the No Surprises Act's balance-billing protections and from the federal IDR process. Air ambulance services are covered.

How many states protect patients from ground ambulance surprise bills?

Between 22 and 24 states, depending on the tracker: Georgetown CHIR counts 22, and the Commonwealth Fund's map lists 24 with protections for fully insured plans.

Can a ground ambulance provider use federal IDR?

No. Federal IDR is limited to items and services the No Surprises Act covers. Ground ambulance disputes follow state law where it applies, or ordinary plan appeals and contract terms.

What happened to the federal ground ambulance committee recommendations?

The GAPB advisory committee approved recommendations in fall 2023 and issued them in 2024, but federal legislative action has stalled.

Sources: Georgetown CHIR / Commonwealth Fund ground ambulance analysis; Commonwealth Fund state law map; CMS GAPB advisory committee; New Hampshire 2025 session law (effective Jan. 1, 2026). IDR Filings is not a law firm and this page is not legal advice.