No Surprises Act and medical transportation: good faith estimates, ambulances, and wheelchair vans

Two protections that reach different patients

The No Surprises Act took effect on January 1, 2022. For a transportation company it does two separate things, and each one protects a different group of patients.

• Limits on surprise bills for insured patients. When a person with an employer plan, an individual plan, or a federal employee plan gets emergency care, certain care at an in-network hospital or surgery center, or an air ambulance ride, an out-of-network provider cannot bill more than the in-network cost share. The air ambulance rule sits at 45 CFR 149.130.
• Good faith estimates for uninsured and self-pay patients. A covered provider gives a written estimate of expected charges when a self-pay patient books a service or asks what it costs (45 CFR 149.610). A patient whose bill lands well above the estimate can dispute it (45 CFR 149.620).

Ground ambulances sit outside the first protection. CMS’s consumer guidance says ground ambulance services generally are not covered by the act’s billing protections and can still charge out-of-network rates unless a state law says otherwise. Wheelchair and stretcher vans are not named in either part. Whether the estimate rule reaches a van company depends on how its state licenses it.

The surprise bill limits do not apply to Medicare or Medicaid, which already restrict what a patient pays. Under 42 CFR 447.15, Medicaid’s payment plus any copay in the state plan is payment in full. Medicare has paid ambulance services only on assignment since April 1, 2002, so an ambulance supplier may collect nothing from the patient beyond the Part B deductible and coinsurance. The Medicaid rider billing guide covers what you may collect from those riders.

Who has to give a good faith estimate

The estimate rule applies to health care providers and health care facilities. A provider is “a physician or other health care provider who is acting within the scope of practice of that provider’s license or certification under applicable State law, including a provider of air ambulance services.” A facility is an institution such as a hospital, surgery center, rural health clinic, laboratory, or imaging center that holds a license as that kind of institution.

CMS’s provider training lists three groups that must comply: physicians, other health care providers acting within their scope of practice under state law, and air ambulance providers. Its applicability FAQs add that the duty to give estimates applies regardless of the clinical setting.

Two parts of the definition matter for rides:

• Coverage is judged one service at a time. A patient counts as uninsured for any service their coverage does not include, even if they have Medicaid, Medicare, or private insurance for other care.
• Choosing self-pay works only for private coverage. A person with an employer plan, individual coverage, or a federal employee plan who decides not to file a claim counts as self-pay. The rule’s self-pay language names those plans and leaves Medicare and Medicaid out.

Nothing in the definition mentions ground ambulances or vans. It turns on state licensure, so your own licenses decide the answer.

Where wheelchair and stretcher van companies land

Start with what your state licenses you to do. Most companies fit one of three situations.

• Licensed to carry passengers. Many ambulatory and wheelchair companies hold a business license, a for-hire or motor carrier permit, and Medicaid or broker enrollment. None of those is a license to give health care, and CMS’s training does not list transportation companies among the providers that must comply. The rule’s definition is a poor fit for them.
• Licensed by a health or EMS agency. Some states license van services under their health codes. New Jersey’s rules define a mobility assistance vehicle service as an entity licensed by the Department of Health to provide “non-emergency health care transportation” (N.J.A.C. 8:40-1.3), and Illinois defines a stretcher van provider as an entity licensed by its Department of Public Health (77 Ill. Adm. Code 515). Neither the federal rule nor CMS’s training addresses licenses like these. If you hold one, giving self-pay riders a written estimate costs little and settles the question.
• Licensed as a ground ambulance service. An ambulance service holds a state EMS license, and the estimate rule has no exception for ground ambulances. Their exception lives only in the surprise bill part. A company that runs ambulances alongside vans should treat scheduled non-emergency ambulance trips for self-pay patients as covered. The guide to adding ambulance service covers that license.

A van company is also not a health care facility under the rule, because that term means licensed institutions such as hospitals and surgery centers. If self-pay work is a large share of your revenue, have a health care lawyer in your state read your licenses against 45 CFR 149.610.

What a good faith estimate has to include

The estimate goes out in writing, on paper or electronically as the patient prefers, and the clock starts when the service is booked or the patient asks about cost.

The rule sets no deadline for a trip booked fewer than 3 business days ahead, such as a ride booked the day before. A cost question still counts, because the rule treats any discussion of cost as a request. The estimate must list:

• The patient. Name and date of birth.
• The service. A plain description and the scheduled date.
• The charges. Each expected item with its service code, diagnosis code where one applies, and expected charge. For an ambulance trip, that means the codes you would bill, such as A0428 for a basic life support non-emergency transport and A0425 for mileage.
• The provider. Your name, NPI, and tax ID, plus the state and location where the service happens.
• The disclaimers. That it is an estimate and not a contract, that actual charges may differ, and that the patient may dispute a bill substantially above it, with instructions on how.

Covered providers also have to tell every self-pay patient that estimates are available: on the website in a way a search engine can find, in the office, and out loud when the patient books or asks about cost.

Standing trips can share one estimate. A single estimate for recurring services may cover up to 12 months if it states the timeframe, the frequency, and the total number of services, which fits a rider on a three-day-a-week standing order. If the scope changes, a new estimate is due at least 1 business day before the service. Estimates become part of the patient’s record, and the patient can ask for a copy of any estimate from the past 6 years.

When the bill comes in higher than the estimate

A bill at least $400 above your estimate opens the door to a federal dispute. The patient has 120 calendar days from receiving the first bill with the higher charges to start patient-provider dispute resolution and must pay a $25 nonrefundable fee. An independent dispute resolution entity then reviews the estimate and the bill. If you settle after the dispute starts, the settlement has to take at least half of the patient’s fee off what they owe. If the reviewer sides with the patient, the $25 comes off the amount owed to you.

An example with made-up numbers: a self-pay family gets an estimate of $380 for a scheduled ambulance transfer, then receives a bill for $820 after an unplanned wait and a longer route. The bill is $440 over, so it qualifies for dispute. The practical fix is to price likely waiting into the estimate and to reissue it whenever the plan changes before the trip.

Ground ambulances: what the federal committee recommended

The act did not ignore ground ambulances. It required HHS, Labor, and the Treasury to convene an advisory committee on ground ambulance and patient billing. The charter was signed on November 16, 2021, the committee met three times between May and November 2023, and it issued its report on August 28, 2024. CMS now lists the committee as inactive, and the report’s recommendations are addressed to Congress and the departments.

The report’s main recommendations:

• Ban balance billing for out-of-network ground ambulance emergency services, tied to a guaranteed minimum payment from health plans.
• Cap the patient’s cost share for those services at the lesser of $100, adjusted each year by CPI-U, or 10 percent of the payment rate, whether or not the plan has a deductible.
• Set the minimum payment from the state balance billing law first, then a state or local regulated rate, then a rate the plan and the ambulance agreed on, and only then a percentage of Medicare set by Congress.

Scheduled transports were left open. A majority wanted the same protections for non-emergency ambulance trips such as discharges and transfers, but the related recommendations did not pass, so the report makes none for those trips. The claims data the committee reviewed, from 2014 to 2017, showed about 90 percent of non-emergency transports provided by private companies and 57 percent delivered out of network.

State ground ambulance laws

States moved first. The committee’s report lists 16 states with ground ambulance balance billing protections as of March 2024: Arkansas, California, Colorado, Delaware, Florida, Illinois, Indiana, Louisiana, Maine, Maryland, New York, Ohio, Texas, Vermont, Washington, and West Virginia. Ohio’s and Vermont’s laws apply only to emergency services. Two of the newer laws show how the protections work.

• California. Under Health and Safety Code 1371.56, for health plan contracts issued or renewed from January 1, 2024, the patient owes an out-of-network ground ambulance no more than the in-network cost share. The ambulance may send only that cost share to collections. It may not report the debt to a credit bureau, may not sue for at least 12 months after the first bill, and may not garnish wages or place a lien on the patient’s home. The plan pays the rate set or approved by the local government or, where there is none, the reasonable-value amount in the state’s managed care regulations. The section excludes Medi-Cal managed care plans.
• Washington. Under RCW 48.49.200, for plans issued or renewed from January 1, 2025, an out-of-network ground ambulance service may not balance bill a patient for covered services. Through December 31, 2027, the plan pays the local government’s rate or, where there is none, the lesser of 325 percent of Medicare’s rate or the billed charge. A patient who overpaid gets a refund within 30 business days, with 12 percent interest after that.

Both laws are written around licensed ambulances. Washington’s applies to organizations licensed by its Department of Health to provide ground ambulance services, which leaves wheelchair vans out. State laws like these also reach only coverage the state regulates. The committee’s report notes that self-funded employer plans are not subject to state insurance laws under ERISA unless the plan opts in where the state allows it. The list of 16 dates from March 2024, so check your state insurance department for anything passed since.

Why a written quote still makes sense

Even where no federal estimate is required, a written price protects you. Several states require advertised and quoted prices to include every mandatory fee, which the guide to all-in price laws covers. A family paying from a health savings account needs an itemized receipt, and a family disputing a card charge will point to whatever you told them on the phone.

A quote that holds up names the base rate, the expected loaded miles, the wait time included and the charge beyond it, any extra attendant, the total, and the cancellation terms. Send it by text or email before the ride and keep it with the trip record. The rate sheet template gives the layout, and the private pay guide covers pricing those trips.

Quoting self-pay trips in HealthRide

In HealthRide, prices come from your rate schedules, set per payer, and are quoted at booking, so the price a family hears and the final charge come from the same rates. When a rider keeps a card on file, HealthRide can charge it once the trip is done and the final fare is set. See payments.