The No Surprises Act (NSA), which took effect in January 2022, was a massive piece of federal legislation designed to protect Americans from devastating, unexpected out-of-network medical bills after receiving emergency care. While it successfully protected millions of patients from surprise hospital and physician network fees, it arrived with one glaring, terrifying loophole.
Ground Ambulances Were Excluded
Due to intense lobbying and the extremely fragmented nature of local EMS contracts (which involve a mix of municipal fire departments, volunteer squads, and private equity-backed corporations), federal lawmakers excluded ground ambulances from the final text of the No Surprises Act.
Currently, the federal No Surprises Act only protects patients from out-of-network Air Ambulance (helicopter) bills.
The State-Level Patchwork
Because the federal government failed to protect ground transit, the battle shifted to state legislatures. As of early 2025, approximately 22 individual states have passed their own sovereign laws attempting to ban or restrict ground ambulance surprise billing.
These protections vary wildly:
- Comprehensive States (e.g., California, Colorado): Strongly protect patients, limiting cost-sharing for out-of-network rides to the patient's standard in-network deductible and copays, and explicitly banning the ambulance company from balance billing.
- Limited States: Only protect patients who are enrolled in specific state-regulated insurance plans, leaving patients with federally-regulated employer plans (ERISA plans) completely exposed.
- Unprotected States: Over half the nation currently relies on zero structural protections, meaning a $3,000 out-of-network bill for a 5-mile ride remains completely legal.
This is exactly why the AmbulanceCost Nationwide Tool cross-references your zip code with active state-level legislation—so you know exactly what legal shields you have available in your jurisdiction.