Expanding the No Surprises Act to Protect Consumers from Surprise Ambulance Bills

Late last year, the Advisory Committee on Ground Ambulance and Patient Billing (GAPB committee) — created as part of the No Surprises Act (NSA) — approved recommendations to federal policymakers for protecting consumers from surprise billing for ground ambulance services. While the NSA protects consumers from many of the most prevalent forms of surprise balance billing by out-of-network providers and facilities in emergency room, air ambulance, and in-network hospital settings, it does not cover ground ambulances. Federal lawmakers decided not to include them in the NSA because of the varied types of ground ambulance services, existing local and state regulations, and a lack of cost data.

It is a pressing issue — an estimated 28 percent of privately insured ambulance rides could result in surprise bills because of ambulance providers being out of network and insurers not paying the full charges. The average surprise bill for private sector transports was $734 with cost sharing of $260; this is somewhat lower for public sector transports.

Fourteen states have enacted ground ambulance surprise billing laws before and after the passage of the NSA — including four this year — but federal action is needed to provide comprehensive protection. Fewer than a third of states have protections in place, and states lack the authority to regulate all types of health insurance — specifically, self-funded employer-sponsored insurance where 65 percent of workers in the U.S. get their coverage.

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GAPB Committee Recommendations

The GAPB committee is composed of advocates from insurance, government, consumers, and emergency medical services. The committee began meeting in May 2023 and heard testimony from experts in the field and received public input. The committee proposed recommendations for Congress that would protect consumers from surprise bills for emergency ground ambulance services, including interfacility transports. The committee also approved payment standards for providers delivering out-of-network services.

If these recommendations become law, consumers will no longer face surprise bills and there will be a method to determine how much payers owe the providers. Consumers’ cost-sharing amounts will be limited and providers of ground ambulance services will be banned from billing for any higher amounts. GAPB rejected the use of an independent dispute resolution (IDR) process (created under the NSA to remove consumers from payment disputes through a third-party, baseball-style arbitration to determine the payment) in favor of a tiered payment standard that relies on state and local rate setting. If no such rate setting exists, the payment standard is benchmarked to Medicare payment rates.

Congress designed the NSA to save federal dollars and reduce premiums below current trends. It is unclear whether the approach recommended by the GAPB will similarly produce savings. There are concerns that the use of state or locally set rates and the backup use of Medicare rates could raise costs. The GAPB passed these decisions on to future deliberations by Congress.

State Action on Ground Ambulance Protections

While the GAPB worked toward a solution at the federal level, states continued to act on their own. This year, Arkansas, California, Louisiana, and Texas passed laws to protect consumers from ground ambulance surprise bills. They join 10 other states with some form of protection in place. Other states are exploring options, including Washington, which recently published recommendations.

States and the GAPB have grappled with the question of reimbursement rate methodology, balancing the need for public and private ambulance companies to be sufficiently funded with controlling costs for consumers and payers. Thirteen of 14 states with ground ambulance protections have opted against using an IDR process, like the GAPB recommendations. Four states do not address payment, but most have chosen to set a payment standard. All four states with new laws use rates set by local government entities as the first standard for a reimbursement rate. Five of the 14 states with ground ambulance protections tie the reimbursement rate to Medicare rates when no other rate has been set.

Looking Forward

The NSA protects consumers from balance billing, with the major exception of ground ambulance services. The Advisory Committee on Ground Ambulance and Patient Billing worked with stakeholders to develop recommendations to protect privately insured consumers from ground ambulance surprise bills while relying on a payment standard that looks first to state and locally set rates. States’ initiatives on these protections are beneficial but not comprehensive since they lack legal authority to regulate all types of private health insurance. This excludes roughly 99.5 million consumers who have insurance under self-funded plans (i.e., plans typically offered by employers that bear insurance risk for their employees) that are not subject to state regulation. The GAPB recommendations include guardrails to encourage state and local entities to consider costs in setting rates, but it left open key details that will affect the potential to reduce costs. Congress now has the roadmap it requested to fill a gap in the NSA and protect consumers, but it is critical that Congress consider overall costs in the ground ambulance sector as it decides how to apply the GAPB recommendations.