Overview
Emergency air ambulance flights are among the most common sources of catastrophic surprise medical bills in the United States. Before the No Surprises Act, patients regularly received air ambulance bills for $50,000–$100,000+ — even when they had insurance — because most air ambulance companies operate out-of-network from all insurers, allowing them to bill at whatever rate they chose.
The No Surprises Act (effective January 1, 2022) specifically extended balance billing protections to air ambulance services from out-of-network providers. Under the law, if you have health insurance, you can only be charged your in-network cost-sharing amount for air ambulance services — regardless of whether the air ambulance company is in your network.
How the Protection Works
Before the No Surprises Act: An air ambulance company could charge $80,000, your insurance paid $15,000 (based on their contracted rate), and the company balance-billed you for $65,000. You had to pay or negotiate.
After the No Surprises Act: The air ambulance company must accept your insurer’s determined amount as payment in full (plus your in-network cost-sharing). They cannot bill you more than what you would owe for an in-network service.
Your cost: Your applicable in-network deductible, copay, or coinsurance — whatever you would owe for any other emergency service under your plan. No more.
Ground Ambulances — NOT Covered
Ground ambulance services are explicitly excluded from the No Surprises Act protections. Ground ambulance balance billing is regulated at the state level, and protections vary widely. Many states have enacted their own ground ambulance protections — check your state’s insurance commissioner website.
What to Do If You Received a Balance Bill
Step 1 — Do not immediately pay. Review the bill carefully. Determine if this was an air ambulance service following a medical emergency.
Step 2 — Contact your insurance company. Ask them to confirm that the claim was processed correctly under the No Surprises Act protections. Request an Explanation of Benefits (EOB) showing your in-network cost-sharing amount.
Step 3 — Write to the air ambulance company. Inform them in writing that the No Surprises Act applies and that you owe only your in-network cost-sharing amount. Reference the specific federal law. Request they reprocess the billing accordingly.
Step 4 — File a complaint with CMS. The Centers for Medicare & Medicaid Services enforces the No Surprises Act. File at cms.gov/nosurprises or call 1-800-985-3059.
Step 5 — File a complaint with your state insurance commissioner. Even with federal protections, your state insurance regulator may also have jurisdiction and can apply additional pressure.
The Independent Dispute Resolution Process
If your insurer and the air ambulance company disagree on the “out-of-network rate” to apply, they use the Independent Dispute Resolution (IDR) process. You are not a party to this process — it’s between the insurer and the provider. Your cost-sharing obligation doesn’t change based on the IDR outcome.
What Most People Don’t Know
- The protection applies regardless of medical necessity determination. You don’t need to prove the flight was necessary to invoke the billing protection.
- Tribal organization exemption: Tribal-operated air ambulances may have different rules — check with your insurer.
- Medicare and Medicaid recipients have separate protections. The No Surprises Act specifically covers privately insured patients. Medicare and Medicaid have their own rate-setting mechanisms.
- The air ambulance company cannot require you to waive your rights. Any form asking you to consent to balance billing for emergency air ambulance services cannot override the federal law.
- Uninsured patients are not protected by the No Surprises Act balance billing rules — but they can request a Good Faith Estimate before any non-emergency service and dispute charges through a separate process.
Legal Basis
- No Surprises Act (Division BB of the Consolidated Appropriations Act of 2021) — 42 U.S.C. § 300gg-111 et seq.
- Specifically: Section 104 (air ambulance) and Section 105 (air ambulance IDR)
- CMS implementing rules — 86 FR 36872
Frequently Asked Questions
Does the No Surprises Act cover ground ambulance bills as well as air ambulance bills?
No. Ground ambulance services are explicitly excluded from the No Surprises Act balance billing protections. Ground ambulance billing is regulated at the state level, and protections vary widely by state. If you received a surprise ground ambulance bill, check your state insurance commissioner’s website for any applicable state-level protections.
What exactly will I owe out of pocket after the No Surprises Act applies to my air ambulance bill?
You owe only your normal in-network cost-sharing — your applicable deductible, copay, or coinsurance — exactly what you would pay if the air ambulance had been an in-network provider. The air ambulance company must accept the insurer’s payment as payment in full and cannot bill you for the remainder.
What if the air ambulance company ignores the law and keeps sending me bills?
Do not pay. Write to the company citing the No Surprises Act (Pub. L. 116-260, effective January 1, 2022) and state that you owe only your in-network cost-sharing. Simultaneously file a complaint with CMS at cms.gov/nosurprises or call 1-800-985-3059. CMS can impose civil monetary penalties on providers who continue balance billing in violation of the law.
I’m uninsured — does the No Surprises Act protect me from large air ambulance bills?
The balance billing cap applies only to insured patients. Uninsured patients are not protected by the No Surprises Act’s air ambulance balance billing rules. However, uninsured patients can request a Good Faith Estimate before non-emergency air transport and dispute bills that exceed the estimate by $400 or more through the Patient-Provider Dispute Resolution process.
Do I need to prove the air ambulance flight was medically necessary to invoke this protection?
No. The No Surprises Act protection applies regardless of any medical necessity determination. You do not need to prove the flight was necessary — the billing protection is automatic for any insured patient who receives air ambulance services from an out-of-network provider.