Why is the Hottest Topic Not Included in the No Surprises Act

With the 2025 legislative sessions in full swing by this point, I wanted to give everyone a glance at one of the hottest topics in the country for the third year running: ground ambulance reimbursement.

Frequent readers may recall that ground ambulances were intentionally left out of the No Surprises Act (NSA) protections, even though studies have reported that it has the highest out-of-network billing rate of any medical specialty. Congress hesitated for a few reasons. One: the different types of private versus public services; two, local governments often oversee ground ambulance transport, and lawmakers didn’t know where and how to step in; and three, because Congress reportedly did not have a large amount of data on the costs of ambulance bills at the time.

They created the Advisory Committee on Ground Ambulance and Patient Billing under the NSA, whose job it was to study and report recommendations to lawmakers on protecting consumers from surprise ground ambulance bills.

As Zelis’s Matthew Albright reported on the Committee’s specific recommendations when its report came out last September, the overarching theme of the report was that Congress should apply the same relationship between federal law and state law that currently exists within the NSA, and respect states that had already passed legislation.

With the federal government relatively silent on the issue, states have continued to hear stories about residents receiving large surprise bills following ground ambulance transport. States began to take things into their own hands, and at present, 19 have some form of law on the issue, and eight states have filed their own new bills in the 2025 session.

While almost all contain consumer protection language, many of the states to examine the issue recently have passed specific reimbursement schemes.

Just a couple of states have some sort of set fee schedule for ground ambulance reimbursement, and just a handful more have a framework whereby the options are simply an ambulance provider’s billed charges or a percentage of the Medicare rate. 

Much more popular in the last two years is a mechanism that authorizes local governments to set a reimbursement rate for transports originating within their jurisdiction. This typically has to be reported and compiled on a public website, often the website of the state’s insurance department.

Texas was an early adopter of this type of legislation, but is a great example of a well-developed reimbursement system that set an example for its surrounding states – most of which filed extremely similar bills of their own the following year. Texas implemented its 2023 bill SB2476 by passing an entire Insurance Department rule on how rates should be submitted, when the rates went into effect, how they’d be updated periodically, and when they’d be published online for the public to access. Effective and public since early last year, the system reportedly has been working well.

There are still major difficulties within the specialty, however. Some states have faced struggles in successfully implementing their protections. Budgetary and staffing concerns can make maintaining a local rate database difficult. States have also differed on whether non-emergency or hospital-to-hospital transports are included in these protections.

And as with state laws, all of these protections only apply to state-regulated, or fully insured, insurance. Many Americans have self-funded plans to which state law does not apply, and therefore are left waiting for congressional action. Some states may even be holding off on passing their own laws because they expect Congress to make a move; the Texas law sunsets in September of this year, because lawmakers back in 2023 assumed a federal setup would exist by now.

With reportedly 60 percent of ground ambulance rides being out-of-network, according to FAIR Health, this is obviously an issue affecting many Americans, and likely contributing to the growing medical debt epidemic.

More than half of U.S. states have examined the issue, and Congress has its best recommendations in hand – all it needs to do is act.