When a medical emergency strikes, the last thing patients should worry about is an unexpected ambulance bill. Yet surprise out-of-network charges—particularly for emergency transportation—remain a persistent burden. While the federal No Surprises Act, implemented in 2022, sought to shield patients from such financial shocks, gaps in enforcement and coverage have left room for improvement. This article examines the law’s real-world impact and analyzes California’s latest regulations designed to address these shortcomings.

The Limits of Federal Protections

The No Surprises Act prohibits balance billing for most emergency services, requiring insurers to cover out-of-network care at in-network rates. However, ground ambulance services—a frequent source of exorbitant charges—were notably excluded from these protections. A 2023 study found that nearly 70% of ambulance rides in the U.S. could result in surprise bills, with costs averaging over $1,200 for advanced life support transports.

California’s Legislative Response

In early 2025, California implemented new rules extending state-level protections to ambulance services. The regulations mandate that insurers must treat emergency medical transportation as in-network, regardless of provider contracts. Additionally, disputes between insurers and providers must now be resolved through mandatory arbitration, removing patients from payment negotiations.

Early data suggests the policy has reduced patient complaints related to ambulance bills by approximately 40% in its first quarter. Yet challenges persist in coordinating between insurers, ambulance companies, and healthcare facilities. Some providers have reported delayed reimbursements, while smaller ambulance operators argue the fixed payment rates threaten their financial viability.

Ongoing Challenges and Future Directions

Experts note that California’s approach, while innovative, may require adjustments to ensure long-term sustainability. Key concerns include the lack of standardized billing practices across ambulance providers and varying interpretations of what constitutes "emergency" transport. The state legislature has proposed additional measures to streamline arbitration processes and establish clearer rate-setting guidelines.

As other states observe California’s experiment, the outcomes may shape future federal amendments to the No Surprises Act. Patient advocacy groups emphasize that true reform will require addressing systemic issues in emergency medical service funding while maintaining access to critical care.

Updated April 12, 2025