A car carrying Nicole Silva's four-year-old daughter was T-boned on the way to a relative's house near La Jara, in southern Colorado. A cascade of ambulance rides followed: a ground ambulance to a local hospital, an air ambulance to Denver, and a second ground ambulance to Children's Hospital Colorado.

One of the three services, Northglenn Ambulance, then publicly run and since acquired by a private company, sent its bill to a debt collector. The amount was $2,181.60. With court fees and interest it grew past $3,000, according to court records cited by KFF Health News, which reported Silva's account in July 2025. Silva is a preschool teacher. She could not pay. The collector garnished her wages.

"It put us so behind on bills, our house payment, electric, phone bills, food for the kids," she said. "It took away from everything."

Her daughter was on Medicaid, which was supposed to cover the transports, so this is not a textbook out-of-network balance bill. That is the point. The ambulance ride is the one medical transaction in which the patient has no leverage before it, during it, or after it. The vehicle arrives, the child is loaded, and the billing follows on its own schedule, addressed to whoever was standing there.

The No Surprises Act was signed on 27 December 2020 as Title I of Division BB of the Consolidated Appropriations Act, 2021, and took effect for plan years beginning on or after 1 January 2022. Its governing idea is narrow and easy to state: a patient should not be charged out-of-network prices for care they had no practical ability to choose. Congress applied that idea to emergency departments. It applied it to the anaesthetist or radiologist who turns out to be out of network inside an in-network hospital. It applied it to air ambulances.

The central provision is codified at 42 U.S.C. § 300gg-111, "Preventing surprise medical bills." The word "ambulance" does not appear in it. Not once, across the full text of the section. The nearest the section comes is "ambulatory," in a list of facilities that includes the ambulatory surgical center.

The omission is architectural. "Emergency services," at § 300gg-111(a)(3)(C)(i), means a medical screening examination "that is within the capability of the emergency department of a hospital or of an independent freestanding emergency department, as applicable, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition," followed by such further examination and treatment as is required "within the capabilities of the staff and facilities available at the hospital or the independent freestanding emergency department." Every clause is anchored to a building.

The next section along, § 300gg-112, is titled "Ending surprise air ambulance bills." It defines its subject in one sentence: "The term 'air ambulance service' means medical transport by helicopter or airplane for patients."

Ground ambulances are not removed by an exclusionary clause. They fall outside a protection built around a building and an aircraft. The missing category is wider than roads, too: the federal law reaches air ambulances but not ground services, including the ambulances that travel by water.

That describes the shape of the statute. It does not explain the shape, and Congress plainly knew the vehicle was missing. Section 117 of the same title, "Advisory Committee on Ground Ambulance and Patient Billing," provides that "[n]ot later than 90 days after the date of enactment of this Act, the Secretary of Labor, Secretary of Health and Human Services, and the Secretary of the Treasury (the Secretaries) shall jointly establish an advisory committee for the purpose of reviewing options to improve the disclosure of charges and fees for ground ambulance services, better inform consumers of insurance options for such services, and protect consumers from balance billing." Its recommendations were to cover, among other things, "legislative options for Congress to prevent balance billing." The report was due "[n]ot later than 180 days after the date of the first meeting of the advisory committee."

The dates are a matter of record. The charter was approved on 16 November 2021, almost eleven months after enactment and roughly eight months after the ninety-day deadline. The first meeting was held on 2 and 3 May 2023, the second on 16 August, the third across 31 October and 1 November. The report is dated 29 March 2024 on its cover. CMS records it as issued on 28 August 2024, five months later. CMS now lists the committee's status as inactive. Federal law has not changed.

The report itself is plainer than its title suggests. The committee "unanimously agreed that unique features of ground ambulance emergency medical services would require substantial modifications to current law to both protect consumers from balance billing and protect their access to emergency services." Its twelfth recommendation is a single line: "Prohibit balance billing and guarantee reasonable payment for ground ambulance emergency medical services."

Set into the summary is the sharpest sentence in the document. Explaining why most members favoured a fixed-dollar cap on cost sharing that would apply before a patient had met their annual deductible, the committee wrote: "They believed this policy would best protect consumers who may fail to call 911 when care is needed for fear of unknown out-of-pocket costs."

A federal advisory committee, convened by three cabinet secretaries and reporting to five congressional committees, recorded that the cost of the gap is partly measured in calls that are never made.

The committee also examined whether the Act's existing machinery could simply be stretched over the vehicle, and found that it could not. The Act allows a patient, in defined circumstances, to be given notice and to consent to out-of-network billing. Applied to ambulances, the committee found that approach "would be unwieldy and impractical," reasoning that "[b]ecause of the nature of 911 ambulance responses, transports, and interfacility transfers, patients would rarely be in a position to read a notice or make a decision to waive their balance billing protections."

A person is loaded into a vehicle. Nobody asks which plan they carry. In many cases nobody present could usefully answer. The committee pressed further and found even the Act's threshold test unsuitable, writing that the prudent-layperson standard "is not broad enough to encompass the range of individuals calling 911," and recommending a broader standard "more closely aligned with a consumer's, caregiver's, or bystander's decision to call 911." The person who summons the ambulance is frequently not the person who receives the bill.

How often does a ride produce one? The best peer-reviewed estimate comes from Loren Adler and colleagues at Brookings, the University of Southern California and Wake Forest, "Ground Ambulance Billing And Prices Differ By Ownership Structure," published in Health Affairs on 18 January 2023. Examining commercial claims, the authors "found that 28 percent of commercially insured emergency ground ambulance transports during the period 2014–17 resulted in a potential surprise bill." The advisory committee, summarising the same study, describes the mechanism behind that number: 85 percent of emergency ground transports in the data were delivered out of network, roughly two-thirds of claims were paid in full, and the remaining 28 percent were paid at less than billed charges. The committee also reproduces the study's caveat, that the findings "may not be generalizable to other commercial payers, so the extent of consumer exposure to balance bills may be greater." The claims run from 2014 to 2017, before the Act existed, and they describe commercially insured patients, which excludes the uninsured and also excludes people like Silva, whose public coverage was supposed to have handled it.

So why the helicopter and not the van?

The answer is a 1978 airline statute. The Airline Deregulation Act, at 49 U.S.C. § 41713, bars states from enacting law "related to a price, route, or service of an air carrier," and an air ambulance is an air carrier. The Department of Transportation puts its own authority the same way: it "has limited authority under the Airline Deregulation Act to regulate the prices, routes, or services of an air carrier, including an air ambulance operator." The National Association of Insurance Commissioners draws the contrast directly — state laws regulating the cost of air ambulance services are preempted, while "in contrast, traditional ground ambulance services are regulated under any applicable state laws."

This is not a theoretical preemption. In March 2021 the Eighth Circuit struck down two provisions of North Dakota Senate Bill 2231 in Guardian Flight LLC v. Godfread, 991 F.3d 916. One prohibited air ambulance providers from billing out-of-network insured patients for amounts their insurers did not pay. The court held that it "effectively caps certain air ambulance prices," and that the Airline Deregulation Act preempted it.

On air ambulances, Congress was the only government that could act, because it had spent four decades telling states they could not. On ground ambulances, states could act, and have.

Congress had also run this exact procedure before. Section 418 of the FAA Reauthorization Act of 2018 established an advisory committee to review options "to improve the disclosure of charges and fees for air medical services, better inform consumers of insurance options for such services, and protect consumers from balance billing." Set that beside Section 117 and the phrasing is nearly interchangeable, one clause swapped for another. The Air Ambulance and Patient Billing committee issued its recommendations in March 2022, fifteen months after Congress had already banned air ambulance balance billing without waiting for them. Air got the study and the statute. Ground got the study.

None of which explains why the gap has survived four years of state legislating. For that, look at who owns the vehicles. The most recent full national accounting is the National EMS Assessment produced for the Federal Interagency Committee on EMS in 2011, which found 40 percent of licensed EMS agencies fire-department-based, 21 percent governmental and not fire-based, 25 percent private and non-hospital, and concluded that "[a]mong reporting States, 60% of EMS agencies operate within governmental structures." Its caveats are heavy: a voluntary survey of state EMS directors, aggregate answers resting on "a combination of fact and opinion," four states not reporting, California among them. Counted by trips instead of agencies, national EMS records for 2010 to 2015 put fire departments at 28.3 percent of Medicare transports and non-fire government at 21.2 percent, against 20.8 percent private non-hospital. No current national breakdown appears to exist.

On either measure, a large share of American ambulance service is a municipal function. A national rule on ambulance billing is therefore a national rule about what counties, cities and fire districts may charge, enforced against them. No source records anyone reasoning that way in 2020. It is the obstacle every state legislature has run into since.

The advisory committee heard that most services are small and locally owned, "privately held, volunteer, or established by a local governing authority," and that roughly 75 percent of them bill fewer than three transports a day. CMS classifies 47 percent as rural or super-rural.

Some committee members "argued that tying payment to the Medicare rates could result in underpayment for ambulance services," citing findings by the Government Accountability Office and the Medicare Payment Advisory Commission "that conclude the current Medicare Ambulance Fee Schedule (AFS) needs revision to appropriately reimburse costs for some services, particularly in geographically isolated, low volume areas."

What an ambulance service sells is mostly availability, and availability has to be paid for whether or not anyone calls. The committee put it this way: "Due to the high fixed costs of equipping, staffing and maintaining readiness of ground ambulance services combined with substantial differences among communities in the number of medical transports over which to recover those costs, there is a large variance in regulated and/or billed rates." A service covering a wide county with few transports has to recover the cost of its empty hours from whoever it can bill. Members and presenters told the committee about "ambulance services closing because their costs exceed their revenues," leaving residents with the loss of "some degree of, if not all," access.

So the balance bill is doing real work. It is a transfer from insured patients unlucky enough to need a ride, toward a standing capacity that the whole county benefits from and almost nobody pays for directly. It functions as a levy that no one voted on, collected at the worst available moment from a randomly selected subset of residents. Set a federal payment floor too low and services close. Anyone proposing to abolish the balance bill has to say what takes over the job it is quietly performing.

Which is more or less what the states have spent the last three years trying to work out, one legislature at a time.

California's AB 716 (Chapter 454, Statutes of 2023) applies to plan contracts issued, amended or renewed on or after 1 January 2024. An enrollee pays no more than the in-network cost-sharing amount, and the plan must then pay the non-contracting ambulance provider directly: at "the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea," and where no local rate exists, at the reasonable and customary value determined under title 28 of the California Code of Regulations. California wrote the local government's own rate into the insurance contract.

North Dakota chose a different anchor. House Bill 1322, enacted in 2025, prohibits balance billing, requires insurers to pay providers directly, and sets out-of-network reimbursement at 250 percent of the Medicare rate or the provider's billed charges, whichever is lower. Air ambulances are carved out, federal law having reached them already. The bill adds sections to chapter 26.1-47 of the Century Code, the same chapter whose air ambulance provisions the Eighth Circuit had struck down four years earlier. The ban North Dakota could not impose on aircraft it has now imposed on vans, in the same chapter of the same code.

Where the multiple lands is the entire fight. Montana legislators weighed 400 percent of Medicare, or a set local rate where one exists, backed by ambulance companies and sponsored by two Republicans; health insurers successfully lobbied against it, arguing the price was too steep. Colorado's legislature passed an expansion covering public ambulance services and transfers between hospitals, unanimously in both chambers, and Governor Jared Polis vetoed it. He wrote that the measure would raise premiums "between 73 cents and $2.15 per member per month," and that "those cost savings are outweighed in my view by the premium increases." Sarah Clerget, lobbying for AHIP in Montana, made the insurers' structural point to legislators: it is already hard to persuade ambulance companies to join networks "because folks are going to need ambulance care regardless of whether their insurance company will cover it."

Even a state that gets the number right runs into a ceiling. State insurance law reaches insurers, and does not reach self-funded employer plans, which answer to federal law. KFF's 2024 employer survey found that 63 percent of covered workers are in self-funded plans. Twenty-four states have some form of ground ambulance protection for people in fully insured plans, by the Commonwealth Fund's count with Georgetown's Center on Health Insurance Reforms; KFF, in July 2025, counted Utah and North Dakota as joining eighteen others. Patricia Kelmar of PIRG, who sat on the advisory committee as its consumer-advocacy representative, stated the arithmetic: "It's why we need a federal ambulance protection law, even if we passed 50 state laws."

The protection Congress enacted covers the surgical assistant a patient never met and the helicopter they did not summon. It stops at the vehicle that arrived because somebody dialled 911. The principle reaches its clearest case inside that vehicle, and the statute reaches its edge there, because in 1978 Congress took the aircraft away from the states and never took the van.

KFF, reporting on the gap, attributed the omission in part to the variety of business models involved, from private companies to volunteer fire departments, and to a lack of data on what rides actually cost. Somewhere in the counties without a state law, and inside the self-funded plans that no state law can reach, are the people the committee described in a single clause: consumers who may fail to call 911 for fear of unknown out-of-pocket costs. Kelmar spelled out what that looks like. "If people are hesitating to call the ambulance because they're worried about putting a huge financial burden on their family, it means we're going to get stroke victims who don't get to the hospital on time. It means that person who's worried it might be a heart attack won't call."

Those calls leave no trace in the claims data. The thinness of the claims data is among the reasons given for leaving the vehicle out.

Source note

Statute. No Surprises Act, Division BB, Title I, Consolidated Appropriations Act, 2021, Pub. L. 116-260, enacted 27 December 2020; applicable to plan years beginning on or after 1 January 2022. Definition of "emergency services" quoted from 42 U.S.C. § 300gg-111(a)(3)(C)(i) (U.S. Code, 2023 edition, GPO). The absence of the word "ambulance" from § 300gg-111 was verified by full-text search of the GPO edition of the section; the only stem match is "ambulatory surgical center." Air ambulance definition quoted from 42 U.S.C. § 300gg-112(c)(1). Section 117 quoted from the text reproduced at Appendix A of the advisory committee's report.

Preemption. Airline Deregulation Act preemption provision at 49 U.S.C. § 41713(b)(1). Departmental characterisation from the U.S. Department of Transportation's air ambulance consumer page; contrast with ground ambulance regulation from the National Association of Insurance Commissioners. Guardian Flight LLC v. Godfread, 991 F.3d 916 (8th Cir., filed 17 March 2021), Nos. 19-1343 and 19-1381, on N.D. Cent. Code §§ 26.1-47-09(3) and 26.1-47-08. Section 418 of the FAA Reauthorization Act of 2018, Pub. L. 115-254, and the March 2022 recommendations of the Air Ambulance and Patient Billing Advisory Committee, from the Department of Transportation's account of that committee.

Advisory committee. Report of the Advisory Committee on Ground Ambulance and Patient Billing: Prevention of Out-Of-Network Ground Ambulance Emergency Service Balance Billing, cover-dated 29 March 2024 and recorded by CMS as issued 28 August 2024; charter approval, meeting dates and current inactive status from the CMS GAPB committee page and the report's own Chapter 1. All committee quotations are verbatim from the report PDF. The five congressional committees are those named in Section 117(e).

Prevalence. Adler L, Ly B, Duffy E, Hannick K, Hall M, Trish E. "Ground Ambulance Billing And Prices Differ By Ownership Structure." Health Affairs 2023;42(2):227-236, published online 18 January 2023, doi:10.1377/hlthaff.2022.00738. The 28 percent figure is quoted from the published abstract. The out-of-network and payment breakdown is the advisory committee's summary of the same finding, not a separate result.

Ownership. National EMS Assessment, Federal Interagency Committee on EMS, published 2011 (EMS agency numbers by organizational type; data unavailable for CA, IL, VA, WA). Trip-share figures from NEMSIS data for 2010–2015, 911 calls with transport for Medicare patients aged 65 and over. No current national ownership breakdown was located; this is stated in the text.

State law. California AB 716, Chapter 454, Statutes of 2023; reasonable-and-customary standard at Cal. Code Regs. tit. 28. North Dakota HB 1322 (2025), adding sections to N.D. Cent. Code chs. 23-27 and 26.1-47. State counts from the Commonwealth Fund / Georgetown CHIR interactive map, which is maintained live, and from KFF Health News in July 2025; the two figures count different things.

Reporting. Nicole Silva's account, the Colorado veto, the Montana bill, and the quotations from Patricia Kelmar and Sarah Clerget are from Rae Ellen Bichell and Katheryn Houghton, "Insurers Fight State Laws Restricting Surprise Ambulance Bills," KFF Health News, 9 July 2025. Self-funded coverage share from KFF's 2024 Employer Health Benefits Survey.

Not established. No source consulted establishes the intent of any individual legislator or official in leaving ground ambulances outside the Act. The preemption account explains why federal action was the only available route for air ambulances; it is not evidence of anyone's stated reasoning in 2020. The date of the Silva collision, and the child's medical outcome, are not given in the reporting consulted and are not stated here.