Ground ambulances are explicitly excluded from the No Surprises Act, so 80% of ambulance rides generate out-of-network bills patients cannot avoid or predict

When you call 911, you do not choose your ambulance provider. The dispatcher sends whoever is closest. Nearly 80% of ground ambulance rides result in out-of-network bills because patients have zero ability to select an in-network provider during an emergency. The average surprise ambulance bill is $450, but bills of $2,000-$8,000 are common for rides under 10 miles. This matters because the No Surprises Act — the federal law specifically designed to eliminate surprise medical bills — deliberately excluded ground ambulances. Air ambulances are covered. Emergency room doctors are covered. Out-of-network anesthesiologists are covered. But the ambulance that brings you to the ER is not. This means a patient who does everything right — goes to an in-network hospital, sees in-network doctors — can still face a surprise bill for the ride there. And because ambulance services are often run by private equity-backed companies or municipal fire departments with opaque pricing, there is no way to comparison shop, no way to negotiate in advance, and no way to opt out. The reason this gap persists is structural: ground ambulance services are regulated by a patchwork of local, county, and state jurisdictions, making federal regulation complex. Congress punted the issue to an advisory committee (the GAPB), which recommended capping patient costs at $100 per ride in late 2023, but implementing that recommendation requires Congressional legislation that has not materialized. Meanwhile, 22 states have passed some form of ground ambulance protection, but those laws only cover state-regulated insurance plans. Sixty-three percent of Americans with employer-sponsored insurance have self-funded plans that are federally regulated under ERISA, meaning state protections do not apply to the majority of working Americans. The result is a deliberate, known hole in federal consumer protection that leaves tens of millions of patients exposed to bills they cannot predict, prevent, or negotiate.