The No Surprises Act, effective January 1, 2022, created substantial protections against surprise medical bills. It covers emergency services, out-of-network providers at in-network facilities, and air ambulances. It does not cover ground ambulances. This exclusion is not an oversight. It was a deliberate legislative choice, and as of September 2026, Congress has not closed it.
What the law covers and what it does not
| Service | No Surprises Act Protection | Self-Pay Impact |
|---|---|---|
| Emergency room (in-network facility) | Protected | Cannot be balance-billed by out-of-network ER physicians |
| Out-of-network provider at in-network facility | Protected | Anesthesiologist, radiologist, etc. cannot balance-bill |
| Air ambulance | Protected | Cannot be balance-billed beyond in-network cost-sharing |
| Ground ambulance | NOT protected | Full balance billing permitted in most states |
| Post-stabilization care you consent to | Varies | If you consent to out-of-network post-ER care, protections may not apply |
What ground ambulance bills look like
According to FAIR Health and CMS data, the average ground ambulance charge ranges from $940 to $1,613 depending on the service level. BLS (Basic Life Support) averages $940 to $1,481. ALS (Advanced Life Support) averages $1,277 to $1,613. For uninsured patients, bills of $1,200 to $3,000 or more are common, and the patient is responsible for the full amount if they have no insurance.
Ground Ambulance Charges by Service Level
Average charge ranges. Sources: FAIR Health, CMS, GAO ground ambulance report. Mileage charges ($10-$25/mile) are additional.
Mileage is billed on top of the base rate, typically $10 to $25 per loaded mile. A 15-mile transport adds $150 to $375 to the base charge. In rural areas where transport distances are longer, the mileage component can exceed the base fee.
State-level protections
Roughly 22 states have enacted their own ground ambulance balance billing protections as of 2026. The strength of these protections varies considerably:
- California: Ambulance providers cannot bill uninsured patients more than the Medicare or Medi-Cal rate.
- Colorado, Maine, Vermont: Prohibit ground ambulance balance billing for insured patients.
- New York: Limits out-of-network ambulance charges under the state surprise billing law.
- Texas: Limits ground ambulance charges to the insurer's usual and customary rate for insured patients, but self-pay patients may still face full charges.
In the remaining states, ground ambulance providers can bill whatever they want, and patients have no statutory protection against the charge.
What to do if you receive a ground ambulance bill
Request an itemized bill showing the service level (BLS or ALS), base rate, mileage, and any supply charges. Compare the base rate against Medicare rates for your region (CMS publishes the ambulance fee schedule). If the charge exceeds 200% of Medicare, call the ambulance provider and ask for a self-pay rate or a payment plan. Many municipal ambulance services have financial hardship programs. Private ambulance companies are less likely to offer discounts but are still negotiable.
If the ambulance service is operated by a local fire department or government agency, check whether the municipality has a financial assistance policy. Some cities and counties offer charity care for ambulance services similar to what hospitals offer under 501(r).
Related on this site
Balance billing and the ambulance gap covers balance billing mechanics in detail.
Self-pay patient rights 2026 covers all federal protections including GFE and dispute resolution.
Elsewhere in the network
Dispute a bill above Good Faith Estimate on saveonsurgery.co covers the dispute process that applies to facility bills but not ambulance bills.