Why Did the No Surprises Act Leave Out Ground Ambulances?

The contradiction is difficult to miss.

If you are rushed to an emergency room and an out-of-network physician treats you there, federal law generally protects you from a surprise out-of-network bill. If a helicopter carries you to the hospital, the same federal law protects you from an out-of-network air-ambulance balance bill.

But if an ordinary ambulance drives you to that hospital?

The federal protection generally stops at the ambulance doors.

As of August 2026, the Centers for Medicare & Medicaid Services explicitly tells privately insured consumers that ground ambulance services are not covered by the No Surprises Act’s billing protections and may still charge out-of-network rates unless state law says otherwise. (CMS)

So why would Congress write a law specifically designed to eliminate medical bills patients cannot reasonably avoid—and leave out one of the clearest examples of a service patients cannot reasonably shop for?

The short answer

Congress did not conclude that surprise ground-ambulance bills were acceptable. It postponed solving them because lawmakers had not resolved a harder question: if the patient is prohibited from paying the difference, how much must the insurer pay the ambulance service instead?

Ground ambulance systems presented an unusually difficult payment problem. They include municipal fire departments, county EMS agencies, nonprofits, volunteer services, hospital systems and private ambulance companies. Their funding can combine insurance payments, local taxes, subsidies and patient bills. State and local governments often regulate or operate the service. Many ambulance organizations have few or no contracts with private insurers, making the No Surprises Act’s reliance on negotiated in-network prices difficult to reproduce. Reliable nationwide cost data were also limited when Congress acted. (Health System Tracker)

There was also a practical political consideration. Contemporary reporting after the legislation passed quoted House Education and Labor Committee Chairman Bobby Scott saying the variety of ambulance arrangements was so extensive that resolving the issue before passing the broader bill might have endangered the entire legislation. Congress instead ordered a federal advisory committee to study ground-ambulance billing and recommend a separate solution. (WRAL News)

That distinction matters.

Ground ambulances were not simply forgotten. They were deferred.

And more than five years after the No Surprises Act became law, that temporary-looking deferral remains a major hole in federal consumer protection.

What does the No Surprises Act actually cover?

Congress enacted the No Surprises Act as part of the Consolidated Appropriations Act, 2021, signed into law on December 27, 2020. Its principal surprise-billing protections took effect January 1, 2022. (GovInfo)

For most people with private health insurance, the law generally prevents an out-of-network provider from shifting an unexpectedly large bill onto the patient in three important situations:

• emergency care covered by the law;
• certain out-of-network care received during a visit to an in-network hospital, hospital outpatient department or ambulatory surgical center; and
• out-of-network air ambulance services. (CMS)

In those protected situations, patients generally pay the applicable in-network cost-sharing amount while the insurer and provider resolve what the provider should ultimately be paid.

That is the essential innovation of the No Surprises Act: remove the patient from a payment dispute the patient had little meaningful ability to prevent.

Ground ambulances seemingly fit that principle almost perfectly.

A person with chest pain does not normally stop the paramedics and ask whether the responding ambulance participates in their Blue Cross PPO. A person unconscious after a collision obviously cannot comparison-shop ambulance networks at all.

Yet CMS’s current consumer guidance says plainly:

“Currently, ground ambulance services aren’t covered by billing protections in the No Surprises Act.”

CMS separately describes ground ambulances as an exception and notes that they may still charge out-of-network rates unless state law provides protection. (CMS)

Congress clearly knew the problem existed

This is why describing the exclusion as a simple oversight is misleading.

Section 117 of the very same law created an “Advisory Committee on Ground Ambulance and Patient Billing.” Congress instructed the committee to study ground-ambulance charges, insurance coverage and ways to protect consumers from balance billing. (GovInfo)

The sequence is therefore important:

Congress protected patients from other major categories of surprise billing.

Congress specifically protected air-ambulance patients.

Congress did not extend the same protections to ground ambulances.

And Congress simultaneously ordered the federal government to study how ground-ambulance balance billing should be addressed.

The statutory record makes the idea that lawmakers simply failed to notice ambulances extraordinarily difficult to sustain.

Why were ground ambulances so difficult to include?

There is no single congressional finding titled Here Is Why We Excluded Ground Ambulances. The strongest explanation has to be reconstructed from the statute, statements by lawmakers and staff at the time, available data, and the subsequent federal advisory process.

Taken together, that record points to several closely connected problems.

1. “Ground ambulance” is not one conventional national health-care market

An anesthesiologist, radiologist or emergency physician generally participates in a recognizable health-care payment market. Insurers negotiate provider contracts. Claims are submitted through established coding structures. Large bodies of commercial and Medicare payment data exist.

Ground EMS is different.

KFF found that 62% of emergency ground ambulance rides in 2020 were provided by fire departments or other government organizations. Private ambulance companies accounted for another 30%, and hospital-owned services approximately 8%. (Health System Tracker)

That means Congress was not merely regulating private medical corporations.

It was potentially dictating payment relationships involving cities, counties, fire districts, hospital systems, volunteer services and private companies—organizations with radically different funding structures and costs.

The federal Ground Ambulance and Patient Billing Advisory Committee later identified state and local government oversight as one of the fundamental characteristics separating ambulance services from the other health-care services covered by the No Surprises Act. Ambulances may also be legally or operationally obligated to respond regardless of the patient’s insurance coverage.

A city may, for example, finance EMS partly through property taxes and partly through patient billing. Another jurisdiction may contract with a private company. A rural volunteer organization may handle only a handful of transports. An urban commercial provider may transport thousands.

Writing one federal payment formula across all of those systems is considerably harder than simply declaring, “No more surprise bills.”

2. Congress did not have a reliable price benchmark

This is probably the most important technical reason.

The No Surprises Act does more than prohibit a provider from billing the patient. It needs a mechanism to determine what happens financially after the patient is removed from the argument.

For much of the care covered by the law, a central reference point is the qualifying payment amount, or QPA, which generally draws on an insurer’s median contracted rates for comparable services in a geographic area. Provider-insurer disputes can then proceed through the law’s federal independent dispute-resolution system.

That approach presupposes that a meaningful market of negotiated in-network prices exists.

For ground ambulances, it often does not.

The federal advisory committee concluded that there were too few negotiated in-network ambulance rates to safely reproduce the existing model. It cited evidence suggesting that as many as 85% of emergency ground-ambulance claims could be out of network, while emphasizing substantial variation in the negotiated rates that do exist.

That 85% figure should not be read as a universal national rate for every insurer and every year. Different studies, datasets and markets produce different figures. KFF’s analysis of large-employer claims, for example, found an out-of-network charge on 51% of emergency ground-ambulance rides in 2018. The point is not that one percentage is universally correct; it is that out-of-network ambulance care is unusually common. (Health System Tracker)

And that creates a circular problem:

If ambulance companies rarely contract with insurers, their “median contracted price” may be a weak representation of what ambulance service actually costs.

The advisory committee ultimately concluded that simply inserting ground ambulances into the existing NSA payment machinery would be inappropriate. Its first formal recommendation was that Congress use the No Surprises Act as a foundation but not add ground ambulance emergency medical services without substantial modifications.

That recommendation was adopted 13–0 among voting committee members.

3. The government did not know enough about what ambulance service actually costs

This problem was especially significant in 2020.

Contemporary reporting described lawmakers as having limited information about the true cost of operating ambulance services. Legislators were confronting an industry in which the expense of keeping crews, vehicles and equipment available 24 hours a day could differ enormously depending on geography, transport volume, staffing model and local requirements. (WRAL News)

The federal government has since begun filling that data gap.

MedPAC’s June 2026 examination of the Medicare Ground Ambulance Data Collection System illustrates why the issue was difficult.

In 2024, approximately 10,600 ground ambulance suppliers and providers delivered 11.3 million transports to fee-for-service Medicare beneficiaries, generating about $5.3 billion in Medicare payments. MedPAC also noted that many existing Medicare ambulance payment adjustments historically were not based directly on provider cost data. (MedPAC)

The newer cost information reveals enormous differences between ambulance organizations.

MedPAC found average cost per transport ranging from about $2,878 among the lowest-volume quartile of organizations to $918 among the highest-volume quartile in its 2022–2023 data. Super-rural services also had higher average costs than urban and rural services. (MedPAC)

The revenue figures reinforce the concern. Among nongovernment organizations, the lowest-volume quartile had a median transport-weighted revenue-to-cost ratio of 0.77, compared with 1.10 for the highest-volume quartile. MedPAC cautioned that these figures should not be interpreted as Medicare profit margins because revenues include multiple sources. Still, they demonstrate how strongly economics can change with scale. (MedPAC)

In other words, a federal payment rule that works perfectly well for a high-volume metropolitan ambulance company could potentially be inadequate for an isolated service that must keep an ambulance and crew ready around the clock even if it handles only a few calls.

That does not justify billing the patient instead.

It explains why lawmakers needed to solve the provider-payment question at the same time.

The hidden question behind surprise billing: If not the patient, then who pays?

This is the part of the policy problem that is easiest to miss.

Suppose an ambulance charges $2,000.

The patient’s insurer says the service is worth $900.

The insurer pays $900.

Without a balance-billing law, the ambulance provider may attempt to collect the remaining $1,100 from the patient.

Congress can prohibit that.

But the prohibition does not make the $1,100 disagreement disappear.

Someone still has to decide whether the proper total payment was $900, $2,000 or something in between.

That is fundamentally what surprise-billing legislation does: it transfers the financial dispute away from a trapped patient and creates rules governing the fight between the provider and insurer.

For hospital and physician services, Congress created a federal dispute-resolution framework.

Ground ambulances complicated that framework because their financing may involve taxpayers and locally established rates in addition to insurer contracts.

Contemporary reporting noted that public ambulance systems commonly receive a mixture of taxpayer support and patient revenue. Some municipal services warned that if patient billing disappeared without adequate insurer reimbursement, the lost revenue would have to come from somewhere—potentially local government. (WRAL News)

That is a legitimate policy problem.

It is not, however, a strong argument for making an emergency patient the involuntary financing mechanism.

The federal advisory committee ultimately reached essentially that conclusion. It unanimously recognized the need to remove patients from these disputes but said that a simple balance-billing ban would not work unless it were paired with appropriate insurer reimbursement, prompt payment requirements and adequate coverage rules.

Why did Congress cover air ambulances but not ground ambulances?

This is perhaps the strangest-looking part of the law.

A helicopter ride costing tens of thousands of dollars received federal protection. A much more common ride down the road in an ambulance did not.

But the regulatory histories are different.

Air ambulances had an unusually clear federal problem because the Airline Deregulation Act preempts states from economically regulating air carriers, including air ambulances, in areas such as rates, routes and services. GAO had documented major balance-billing exposure among privately insured air-ambulance patients well before the No Surprises Act. In its 2019 analysis, 69% of approximately 20,700 privately insured air-ambulance transports in the dataset were out of network, and nearly all of the consumer complaints from two states that supplied dollar amounts involved balance bills above $10,000. (GAO)

HHS later summarized the consequence: federal aviation law prevented states from directly regulating air-ambulance prices, making a federal solution particularly important. The No Surprises Act therefore prohibited surprise air-ambulance balance billing beginning in 2022. (ASPE)

Ground ambulances presented almost the inverse regulatory situation.

Instead of states being largely blocked by federal aviation law, state and local governments were already deeply involved in operating, licensing, funding and sometimes setting rates for ground EMS.

That did not make ground-ambulance surprise billing less serious.

It made federal standardization more complicated.

Was ground ambulance exclusion the result of lobbying?

This is an understandable suspicion, but the available evidence does not strongly support it as the primary explanation.

Health-care legislation frequently involves powerful industries trying to shape reimbursement rules, and ambulance providers certainly had financial interests in the outcome. It would be naive to assume that stakeholder pressure played no role anywhere in the policy process.

But that is different from demonstrating that a powerful ambulance lobby successfully purchased or forced a special exemption.

Contemporaneous reporting based on interviews with legislators and congressional staff specifically reported that they did not attribute the omission to a large ambulance-industry lobbying campaign. Instead, they pointed to the diversity of providers, state and local jurisdiction, incomplete cost information and concern about making an already difficult surprise-billing compromise even harder to pass. (WRAL News)

That explanation also fits the statutory evidence better.

If Congress simply intended to protect ambulance companies from regulation, it would be strange for the same legislation to create a federal committee expressly charged with finding ways to prevent ambulance balance billing. (GovInfo)

Evidence-weighted assessment

The strongest answer, therefore, is less conspiratorial and in some ways more frustrating:

Congress knew there was a problem, decided it was too complicated to solve within the 2020 compromise, and postponed it.

Why couldn’t Congress just add ambulances to the existing No Surprises Act later?

The federal committee created to solve this problem eventually concluded that Congress should protect patients—but also that the existing law cannot simply be copied and pasted onto ambulances.

One problem is the QPA benchmark discussed above.

Another is arbitration.

The No Surprises Act’s independent dispute-resolution system can make sense when sophisticated insurers and health systems are fighting over substantial volumes of claims. The ambulance committee noted that approximately 75% of ground ambulance services bill fewer than three transports per day. Members worried that arbitration fees and administrative costs could sometimes rival or exceed the amount actually being disputed, particularly for small organizations.

Then there is the basic definition of emergency care.

Much of the existing No Surprises Act was constructed around care connected to hospitals, emergency departments and other specified facilities. Ambulance medicine happens before the patient reaches those buildings—and sometimes without a hospital trip at all.

An ambulance crew may treat someone at the scene without transport. It may transport a patient between medical facilities. It may take a patient somewhere other than a conventional emergency department. The federal committee concluded that ground ambulance emergency services need their own statutory definition rather than being squeezed into the law’s existing facility-oriented definitions.

And the No Surprises Act’s notice-and-consent mechanism is almost absurd in the 911 context.

A patient experiencing a stroke, major trauma or loss of consciousness is hardly in a meaningful position to review an out-of-network disclosure and negotiate whether to waive federal billing rights. The committee specifically concluded that those procedures would be impractical for emergency ambulance responses.

What did the federal ambulance committee ultimately recommend?

The Advisory Committee on Ground Ambulance and Patient Billing held three public meetings in 2023 and issued its final report on August 28, 2024. CMS now lists the committee as inactive. (CMS)

Its recommendations amount to a blueprint for closing the loophole.

The committee recommended that Congress require health plans that cover emergency services to cover emergency ground ambulance services as well—including qualifying interfacility transport and situations in which an ambulance responds but ultimately does not transport the patient. Such coverage would apply regardless of whether the ambulance provider participates in the insurer’s network and without prior authorization.

It also recommended:

• prohibiting balance billing;
• establishing a maximum patient cost-sharing amount equal to the lesser of $100, adjusted for inflation, or 10% of the applicable ambulance payment rate;
• counting that payment toward the patient’s in-network deductible and out-of-pocket maximum;
• requiring insurers to pay ambulance providers promptly and directly; and
• establishing a payment hierarchy rather than simply importing the existing QPA/arbitration system.

That proposed payment hierarchy is particularly important.

The committee recommended looking first to an applicable state balance-billing law. If none exists, an appropriately regulated state or local ambulance rate could control. If neither exists, the parties’ negotiated rate could apply. And if none of those options exists, Congress could establish a percentage of Medicare or another federal benchmark.

That is a much more tailored system than merely saying, “Treat ambulances exactly like anesthesiologists.”

Five years later, Congress has much better data than it had in 2020

The original justification for delay becomes harder to defend indefinitely.

When the No Surprises Act was negotiated, lawmakers could reasonably point to major gaps in national ambulance cost information.

That is increasingly less true.

The Medicare Ground Ambulance Data Collection System now provides extensive information about costs, revenues, staffing, ownership, transport volume and geographic differences. MedPAC’s 2026 analysis says the dataset marks the first time most ambulance organizations have submitted this type of cost-and-revenue information to CMS, while also cautioning that early reporting errors remain and recommending continued data collection. (MedPAC)

Meanwhile, Congress also has the detailed recommendations of the advisory committee it specifically created to solve the surprise-billing problem.

In other words, the explanation for the 2020 exclusion and the explanation for the continued 2026 exclusion are no longer identical.

In 2020, Congress could credibly say: We do not yet know enough to build the payment system safely.

By 2026, it has substantially more information and an explicit federal policy blueprint.

Yet CMS still tells consumers that federal No Surprises Act protection generally does not extend to ground ambulances. (CMS)

That is now less a research problem than a legislative one.

Have states fixed the problem instead?

Some have—but that does not eliminate the federal gap.

The Commonwealth Fund’s current tracking identifies 24 states with some form of ground-ambulance surprise-billing protection for people enrolled in fully insured plans. Those state laws differ considerably in which services and ambulance providers they cover and in how insurers must reimburse out-of-network services. (Commonwealth Fund)

That still leaves a major jurisdictional problem.

Many Americans receive health coverage through self-funded employer plans governed by ERISA. In general, those plans are not subject to ordinary state insurance regulation, although some may voluntarily opt into state surprise-billing systems where allowed. The federal ambulance advisory committee specifically identified that limitation.

The Commonwealth Fund likewise notes that state laws cannot comprehensively solve the problem because states lack authority over self-funded employer health plans covering a large share of American workers. (Commonwealth Fund)

This is one of the strongest arguments for federal action.

A patient’s protection from an unavoidable ambulance bill should not depend on an obscure distinction between a fully insured employer plan and a self-funded employer plan—something many employees do not even know about until a billing dispute occurs.

So is the ground-ambulance exception defensible?

There are really two separate questions.

Was the original 2020 decision understandable?

Yes.

Ground ambulance financing really is unusually complicated. The system contains thousands of public, nonprofit and private organizations with wildly different call volumes and costs. State and local governments play an important role. Contracted insurance rates are sparse in many markets. And imposing a reimbursement formula that is too low could create genuine access problems, particularly for low-volume or geographically isolated EMS systems.

Those concerns are supported by substantially more than industry rhetoric. Federal data now demonstrate enormous cost differences between providers. (MedPAC)

Does that justify leaving patients exposed indefinitely?

Much less convincingly.

The policy complexity explains why Congress could not simply prohibit ambulance balance bills without simultaneously establishing a reimbursement system.

It does not explain why an unconscious patient, a parent calling 911 for a child, or someone being transported during a medical emergency should function as the fallback mechanism for resolving a pricing dispute between an insurer and an ambulance organization.

The federal advisory committee reached broad agreement on precisely that point: patients should be removed from the dispute, while insurers and ambulance organizations operate under a reimbursement system designed specifically for ground EMS.

Congress now possesses something it did not have in December 2020: substantially better cost data, several years of state experiments, and a detailed federal recommendation for how to structure a national solution.

The real answer to why ground ambulances were left out

The most accurate explanation is neither “Congress forgot” nor “ambulance companies secretly bought themselves a loophole.”

It is more mundane—and more revealing about how American health policy gets made.

Congress was trying to pass a fragile national compromise on surprise medical billing. Ground ambulances presented an unusually fragmented system involving private insurers, private ambulance companies, hospitals, municipal governments, fire departments, taxpayers and state regulators. Lawmakers did not have adequate cost data or a reliable national payment benchmark, and they feared that resolving those questions could jeopardize the larger bill. So they protected patients elsewhere, created a federal study process for ambulances, and postponed the hard decision. (WRAL News)

The postponement was supposed to produce information.

It did.

The federal committee has now recommended prohibiting ambulance balance billing. The federal government is collecting substantially better cost data. States are testing multiple reimbursement models. (CMS)

Yet the federal protection still has not followed.

That makes the unanswered question in 2026 somewhat different from the unanswered question in 2020.

It is no longer simply:

Why did Congress leave ground ambulances out?

We now have a fairly good answer to that.

The harder question is:

Now that Congress has the information it said it needed, why are patients still being left in the middle?

Frequently Asked Questions

Does the No Surprises Act cover ground ambulances?

Generally, no. CMS currently states that ground ambulance services are not covered by the federal law’s surprise-billing protections, although a state law may separately protect you. (CMS)

Does the No Surprises Act cover air ambulances?

Yes. For private insurance subject to the law, the No Surprises Act generally protects patients from out-of-network balance billing for covered air-ambulance services and limits the patient’s responsibility to applicable in-network cost sharing. (CMS)

Why can an ambulance be out of network if I have no choice which ambulance comes?

Because network status depends on whether the ambulance provider and insurer have a contractual relationship—not on whether the patient had a meaningful opportunity to choose the provider. Ground ambulance systems have historically had exceptionally high out-of-network rates. (Health System Tracker)

Was the ground-ambulance exclusion an accident?

The evidence strongly suggests otherwise. The same legislation that created the No Surprises Act established a federal advisory committee specifically to study ground-ambulance balance billing and recommend consumer protections. (GovInfo)

Why didn’t Congress simply ban ambulance balance billing?

Because banning the patient’s bill requires deciding what the insurer must pay instead. Ground ambulance organizations have highly variable costs, extensive state and local regulation, unusually low network participation in many markets and relatively few reliable contracted rates from which to construct a national benchmark.

Are any Americans already protected from surprise ground-ambulance bills?

Yes. State protections have expanded. The Commonwealth Fund currently identifies 24 states with some protection for people in fully insured plans, although the scope differs by state. Those laws generally cannot bind self-funded ERISA employer plans unless a permitted opt-in mechanism is used. (Commonwealth Fund)

What should I do if I receive a surprise ground-ambulance bill?

First compare the ambulance bill with your insurer’s explanation of benefits and determine whether the ambulance was treated as out of network. Then check whether your state has a ground-ambulance balance-billing law and whether your health plan is subject to it. CMS provides an online action-plan tool and the federal No Surprises Help Desk for consumers who need help determining which protections or regulators apply. The federal advisory committee has specifically recommended using that help desk to route ambulance-billing disputes to the appropriate insurer, provider, state regulator, CMS or Department of Labor authority. (CMS)

Conclusion

The ground-ambulance exception to the No Surprises Act looks irrational from the patient’s perspective because, from the patient’s perspective, it is difficult to identify a service more deserving of surprise-billing protection.

You cannot realistically negotiate a network contract while dialing 911.

Congress understood that in 2020.

But eliminating the patient’s bill required Congress to decide how much insurers should pay a fragmented network of ambulance providers whose financing and costs vary dramatically from one community to another. Rather than risk collapsing the larger surprise-billing compromise, lawmakers postponed the issue and commissioned further study.

That explanation is well supported by the historical record.

What is increasingly difficult to explain is why the postponement continues.

Federal policymakers now have years of additional data, state experience and a detailed advisory committee recommendation that explicitly calls for prohibiting balance billing while creating a specialized reimbursement framework for ground EMS.

The No Surprises Act’s ambulance gap began as a legislative deferral. More than five years later, it has become a policy choice Congress is continuing to make.

References and Further Reading

• Centers for Medicare & Medicaid Services — Know Your Rights With Insurance — Current federal consumer guidance explaining what the No Surprises Act covers and the ground-ambulance exception. (CMS)
• Public Law 116-260 — Consolidated Appropriations Act, 2021 — Full statutory text containing the No Surprises Act and Section 117’s ground-ambulance advisory committee. (GovInfo)
• CMS — Advisory Committee on Ground Ambulance and Patient Billing — Official committee history, membership, meetings and final-report materials. (CMS)
• CMS — Report of the Advisory Committee on Ground Ambulance and Patient Billing — The federal committee’s detailed findings and recommendations for eliminating ground-ambulance balance billing.
• MedPAC — June 2026 Report to Congress: Assessment of the Medicare Ground Ambulance Data Collection System — Current federal analysis of ambulance costs, revenues, ownership, transport volume and geographic variation. (MedPAC)
• Peterson-KFF Health System Tracker — Ground Ambulance Rides and Potential for Surprise Billing — Analysis of ambulance ownership, network participation and surprise-billing exposure. (Health System Tracker)
• Sarah Kliff and Margot Sanger-Katz/The New York Times, archived by WRAL — Why Ambulances Are Exempt From the Surprise Billing Ban — Important contemporaneous reporting on why lawmakers deferred ground ambulances during the 2020 negotiations. (WRAL News)
• U.S. Government Accountability Office — Air Ambulance: Available Data Show Privately-Insured Patients Are at Financial Risk — Federal research documenting out-of-network air-ambulance exposure before passage of the No Surprises Act. (GAO)
• HHS Office of the Assistant Secretary for Planning and Evaluation — Air Ambulance Use and Surprise Billing — Federal analysis of air-ambulance billing and the effect of federal aviation preemption.
• The Commonwealth Fund — Map of State Ground-Ambulance Surprise-Billing Laws — Continuously updated tracking of state consumer protections. (Commonwealth Fund)
• The Commonwealth Fund — Consumers Still Face Surprise Bills for Ground Ambulances — States Are Trying to Protect Them — 2026 examination of the continuing federal gap and recent state action. (Commonwealth Fund)