Because the federal government omitted ground ambulances in the landmark 2022 No Surprises Act, safeguarding patients from catastrophic emergency transport debt has fallen squarely upon individual state legislatures. The result is a highly fragmented patchwork of protections.
The Comprehensive States
A growing forefront of roughly 14 states enforce Comprehensive Defenses. States like California, Colorado, New York, Ohio, and Maryland strictly mandate that patients are only liable for their standard in-network cost-sharing, outright banning the ambulance companies from balance billing the patient for the remainder of the charge. The provider and the insurance company are legally forced into arbitration or preset metrics to negotiate the rest behind closed doors.
The Partial Protections
Another tier of states offers Partial Defenses. These laws might enforce protections but only for highly specific situations—such as transports between two in-network hospitals, or specifically governing public fire departments while leaving private and out-of-state entities unregulated. It often takes an expert to decipher exactly when these protections apply.
The Unprotected Majority
Troublingly, well over half the states in the U.S. currently possess no distinct ground ambulance balance billing protections. In these geographic zones, if a patient climbs into an out-of-network ambulance, they remain 100% legally liable for the difference between the insurer's arbitrary "allowed amount," and the provider’s hyper-inflated "sticker price."
What you can do: If battling a surprise bill, always research your state's specific Department of Insurance website. Filing an official complaint with your State Attorney General frequently triggers a rapid regulatory review of the bill.