No Surprises Act and Air Ambulance

What does the No Surprises Act do for air ambulance service?

CMS consumer guidance says surprise bills are generally prohibited for covered air ambulance services furnished by an out-of-network air ambulance provider. The protection includes medical transport by fixed-wing airplane and rotary-wing helicopter when the applicable requirements are met.

Before these protections, an out-of-network provider could bill a patient for the difference between the provider's charge and the combination of the plan payment and patient cost-sharing. That additional amount is commonly called a balance bill. The federal rule generally removes the protected patient from that payment dispute.

Which health plans are generally included?

CMS states that the air ambulance balance-billing protections generally apply to people enrolled in:

• Employer group health plans, including self-funded employer plans.
• Group or individual health insurance coverage.
• Federal Employees Health Benefits plans.
• Marketplace plans and other individual-market coverage.

The rules discussed on this page do not apply in the same way to Medicare, Medicaid, Indian Health Service, Veterans Affairs health care, or TRICARE. Those programs have other payment and billing protections. Short-term limited-duration insurance, health care sharing ministries, and certain fixed-indemnity products also may fall outside these No Surprises protections.

Use the identification card and governing plan document to identify the coverage. When uncertain, ask the plan whether it is subject to the federal No Surprises Act air ambulance provisions and whether a state protection also applies.

Why are the words covered air ambulance service essential?

The federal protection applies when air ambulance benefits are available for the service under the plan or coverage. CMS gives a direct example: if a plan covers air ambulance only for emergencies, the No Surprises Act does not require that plan to cover a non-emergency air ambulance flight or limit the patient's charge for that non-covered flight.

That distinction creates two different questions:

A coverage denial usually follows the plan's claim and appeal process. A suspected No Surprises violation can be raised with the provider, plan, and federal or state help resource. Depending on the facts, both issues may exist in the same case.

How is protected patient cost-sharing treated?

When the No Surprises Act applies to a covered out-of-network air ambulance service, CMS states that the patient's cost-sharing requirement cannot be greater than it would have been for an in-network service. Applicable cost-sharing payments also must count toward the in-network deductible and in-network out-of-pocket maximum under the federal rules.

This does not mean the patient always owes zero. A deductible, coinsurance, or copayment may still apply under the plan. Review the explanation of benefits for:

• Whether the service was covered or denied.
• The provider's network status.
• The amount allowed under the plan's No Surprises processing.
• The stated patient responsibility.
• How the amount was credited to in-network accumulators.

The provider's billed charge, plan payment, allowed amount, and patient responsibility are separate figures. Compare the provider bill with the explanation of benefits rather than relying on one document alone.

Can an air ambulance provider ask the patient to waive this protection?

Notice-and-consent waivers exist for some out-of-network services in other settings. CMS's federal surprise-billing decision tree states that an air ambulance service provider may never seek a patient's consent to waive No Surprises Act protections for an out-of-network air ambulance service.

If an air ambulance provider presents a form that appears to waive the federal balance-billing protection, keep a copy and contact the No Surprises Help Desk before signing when circumstances allow. This is separate from ordinary medical consent, transport authorization, privacy forms, and financial agreements that do not purport to waive federal rights.

Are ground ambulance legs outside the federal protection?

A fixed-wing bed-to-bed transport commonly includes a ground ambulance before the flight and another after landing. CMS explains that ground ambulance services generally are not covered by the federal No Surprises balance-billing protections, although a state law may provide different protection.

That means one itinerary can contain a federally protected air segment and separately billed ground segments with different network and billing rules. Identify each provider and claim. Ask the plan and applicable state insurance department about the ground legs rather than assuming the air protection extends to them.

What should you do if an air ambulance bill looks wrong?

1. Match the bill to the explanation of benefits

   Confirm the patient, date, provider, air or ground segment, claim status, network status, and stated patient responsibility.

2. Ask whether the air service was covered

   If the plan denied coverage, obtain the denial reason, governing plan language, evidence reviewed, and appeal instructions.

3. Ask how No Surprises processing was applied

   If the covered air provider was out of network, ask the plan how cost-sharing was calculated and credited to in-network accumulators.

4. Contact the provider about a mismatch

   Send a copy of the relevant explanation of benefits and ask the billing office to review any amount above the plan's stated patient responsibility.

5. Use the proper review path

   Use the plan appeal process for a coverage denial. Report a suspected federal billing violation to the No Surprises Help Desk. Keep confirmation numbers and copies.

CMS accepts No Surprises questions and complaints online. The federal Help Desk can also be reached at 1-800-985-3059. CMS advises keeping the bill, explanation of benefits, plan documents, relevant correspondence, and any notice or consent form.

Is the provider-plan payment dispute the patient's negotiation?

The federal Independent Dispute Resolution process addresses certain payment disputes between providers and health plans. It is different from a member's coverage appeal and different from the uninsured or self-pay patient-provider dispute process.

A protected patient generally should not be placed between the plan and air ambulance provider to negotiate the provider payment. The patient should focus on whether coverage was correctly decided, whether cost-sharing was correctly calculated, and whether the provider bill matches the protected responsibility.

What protections apply to uninsured and self-pay patients?

The out-of-network balance-billing rules described above are tied to applicable health coverage. Uninsured or self-pay patients instead may have federal rights to receive a Good Faith Estimate from an air ambulance provider and to dispute an eligible bill that is at least $400 above that provider's estimate.

See the Good Faith Estimate section of the quote guide and use current CMS instructions. A commercial quote and a federal Good Faith Estimate may cover different organizations or charges.

What is AirMedHub's role?

AirMedHub can identify the air and ground providers in a proposed itinerary and organize the plan contact and documents supplied for coordination. It is not the health plan, provider billing office, federal regulator, legal representative, or direct air carrier.

AirMedHub cannot decide whether the No Surprises Act applies to an individual bill, calculate legally required cost-sharing, resolve a provider-plan dispute, guarantee coverage, or file a complaint or appeal without separate lawful authority.

Frequently asked questions about the No Surprises Act and air ambulance

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