Air ambulance bills and the No Surprises Act: what you owe

A medical helicopter or plane may have saved precious time. Then a bill arrives for tens of thousands of dollars. Before you pay any of it, check whether federal law limits what you owe.

For most people with private insurance, it does. This guide explains what the No Surprises Act does for an air ambulance bill, who isn't covered, and what to do if you're billed. It's part of our guide to ambulance bills. If you rode in a ground ambulance, see our guide to a ground ambulance bill, since different rules apply.

Why this happens: why air ambulance bills run so high

Air ambulance rides are costly, and you rarely get to choose the company. Before the No Surprises Act, many people got large balance bills.

• High prices. A 2019 Government Accountability Office (GAO) report found median charges of about $36,400 for a helicopter ride and $40,600 for an airplane ride in 2017.
• Few network contracts. The same report found that 69% of air rides in its private insurance data were out-of-network in 2017.
• Bills sent early. An air ambulance may bill you before your plan finishes the claim.
• Coverage gaps. Your plan may deny the ride as not medically necessary, or it may not cover non-emergency rides.

That GAO data is from before the law. Today, what matters most is whether the law applies to you.

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

Since January 1, 2022, the law has protected most people with private insurance. That includes job-based plans, Marketplace plans, and plans you buy on your own. If your plan covers air ambulance rides, here's what it requires:

1. In-network cost sharing. Your copay, coinsurance, or deductible must be the same as if the air ambulance were in your network.
2. A fair base for your share. Your plan figures your share using the lesser of the billed charge or the qualifying payment amount. That amount is generally based on the median rate plans pay in-network providers in the area.
3. It counts toward your limits. What you pay counts toward your in-network deductible and out-of-pocket limit.
4. No balance bill. An out-of-network air ambulance can't bill you more than your cost sharing.
5. A timely decision. Your plan must send the air ambulance a payment or a denial within 30 calendar days of getting the bill.

These rules apply to helicopters and airplanes. They apply even if your plan has no air ambulances in its network. They may even apply if you were picked up outside the United States.

What isn't covered

The law has limits. It doesn't protect you in these cases:

• Your plan doesn't cover the ride. Plans don't have to cover non-emergency air rides. If yours covers only emergencies, a planned air transfer may not be limited.
• Your plan denied the ride. If your plan says the ride wasn't medically necessary, you'll need to appeal. The law limits your share only for covered rides.
• Some kinds of coverage. Short-term plans, health care sharing ministries, and fixed indemnity plans aren't covered.
• Medicare, Medicaid, and other public coverage. The law doesn't apply to Medicare, Medicaid, TRICARE, VA care, or Indian Health Service. These programs have their own protections.

Medicare and Medicaid rules for air rides

Medicare may cover an emergency air ride when you need fast transport a ground ambulance can't give. That's usually because your pickup spot is hard to reach by road, or distance or traffic would delay care.

With Original Medicare, you pay 20% of the Medicare-approved amount after the Part B deductible. All ambulance companies must accept that amount as payment in full. If you have Medicaid, providers that accept Medicaid generally must accept its payment as payment in full.

If you're uninsured or paying yourself

You won't get an estimate for emergency care. But for a planned air ride scheduled at least 3 business days ahead, the air ambulance must give you a good faith estimate. You can dispute a bill that's $400 or more above it. See our guide to a good faith estimate dispute.

The payment dispute between the air ambulance and your plan

The air ambulance and your plan may disagree about what your plan should pay. That's between them, not you.

They first have 30 business days to negotiate. If that fails, either side can start the federal independent dispute resolution (IDR) process within 4 business days. A certified reviewer picks 1 of the 2 offers.

The result changes what your plan pays the air ambulance. Your plan can't raise your share because of it, and the air ambulance can't bill you the difference.

Say Andre has a job-based plan with a $2,000 deductible, 20% coinsurance, and a $6,000 out-of-pocket limit. He hasn't paid toward any of them this year. After a crash, an out-of-network helicopter flies him to a trauma center. His plan covers emergency air ambulance rides.

The air ambulance bills $52,000. His plan's qualifying payment amount is $25,000.

His share is his $2,000 deductible plus 20% of the other $23,000. That's $2,000 + $4,600 = $6,600. But his out-of-pocket limit is $6,000, so he owes $6,000.

Line	Amount
Air ambulance's charge	$52,000
Plan's initial payment	$19,000
Andre's in-network share	$6,000
Bill the air ambulance sends Andre	$33,000
Amount the law doesn't let it bill him	$27,000

The bill asks for $52,000 − $19,000 = $33,000. Andre owes only $6,000, so the other $27,000 is a balance bill. The air ambulance can take that gap up with his plan, through negotiation or IDR. Andre pays $6,000 and keeps a copy of his explanation of benefits (EOB).

What to do if you get an air ambulance bill

1. Don't pay yet. Wait for your EOB. It shows how your plan processed the claim and what you owe.
2. Check your share. Your EOB should show in-network cost sharing. If it shows out-of-network rates, call your plan and ask it to reprocess the claim under the No Surprises Act.
3. Compare the bill to the EOB. If the bill asks for more than your share, the extra is likely a balance bill. Our guide to comparing your medical bill vs. EOB shows how.
4. Call the air ambulance. Say the No Surprises Act applies and ask for a corrected bill. Ask it to hold your account while it checks.
5. Put it in writing. Our surprise bill dispute letter gives you the words.
6. Appeal a denial. If your plan denied the ride, file an internal appeal within 180 days of the denial notice. Include the trip record and your medical records. See what to do when insurance didn't pay a medical bill.

Our guide to whether the No Surprises Act applies covers the other situations the law protects.

When to get help

You can often fix an air ambulance bill with a few calls. It's worth getting help when:

• The air ambulance won't correct a balance bill after you cite the law.
• Your plan processed the ride at out-of-network rates and won't fix it.
• Your plan denied the ride, and your first appeal failed. See our guide to external review for health insurance.
• The bill is already in collections.

For surprise bills, call the No Surprises Help Desk at 1-800-985-3059. You can also file a complaint online. For Medicare, call 1-800-MEDICARE (1-800-633-4227), or get free counseling from your State Health Insurance Assistance Program.

A medical bill advocate can make the calls for you. For a very large bill or a lawsuit, an attorney can explain your options.