States have enacted surprise billing protections stronger than the federal No Surprises Act requires, particularly for ground ambulances and emergency services. However, a major gap exists: state protections apply mainly to fully insured health plans, leaving workers and families covered by self-insured employer plans unprotected—and self-insured plans cover about 60% of the insured population. The federal No Surprises Act, which took effect in January 2022, set a national floor for surprise billing protections.
State laws can build on that floor, and many have. But not everyone benefits equally. Understanding which law applies to you—state or federal—determines whether you're genuinely protected or still at risk.
Table of Contents
- Ground Ambulances—Where State Law Fills a Federal Gap
- The ERISA Exemption—Why Most Employer Coverage Falls Through
- How States Strengthen the Federal Floor Without Preemption
- How to Know If You're Protected and What to Do
- Frequently Asked Questions
Ground Ambulances—Where State Law Fills a Federal Gap
The No surprises Act explicitly excludes ground ambulance services from federal surprise billing protections. This gap has prompted 22 states to enact their own ambulance surprise billing laws, filling what federal law left open, according to the Commonwealth Fund. State protections for ambulances vary significantly.
Illinois imposes a hard ceiling: patients pay the lesser of their normal copayment or 10% of the service cost, which is stricter than federal requirements. Oregon requires a different safeguard—local jurisdictions must publicly justify their ambulance rates to prevent arbitrary rate-setting, a transparency requirement the federal law does not mandate. Some states continue to expand their scope.
West Virginia initially limited protections to HMO plans only, but expanded coverage to non-HMOs effective 2027, showing how state laws can evolve. Even so, state ambulance protections reach only about 40% of the insured population because of a separate federal barrier.
The ERISA Exemption—Why Most Employer Coverage Falls Through
State insurance laws apply only to health plans that are fully insured by state-regulated insurers. Self-insured employer plans—where the employer itself bears the risk and pays claims—are governed by federal ERISA law and are exempt from state insurance protections. This distinction sounds technical but has a concrete effect: state surprise billing laws protect only about 40% of the insured population, according to the Commonwealth Fund's analysis of state ambulance laws.
The numbers are substantial. Approximately 67% of workers with employer health coverage have self-insured plans, meaning they receive no protection from their state's surprise billing laws. A person working for a large employer covered by a self-insured plan is protected by federal law only, not by any state protections that might otherwise apply in their state. For anyone unsure which type of plan they have: contact your employer's benefits department or your plan's customer service line and ask whether your health plan is "fully insured" or "self-funded." If self-funded, ERISA governs surprise billing disputes, and state law does not help.
How States Strengthen the Federal Floor Without Preemption
The federal No Surprises Act explicitly preserves state authority to enforce more restrictive surprise billing laws. States can extend protections to circumstances not covered federally, impose stricter transparency requirements on insurers, or change how disputes are resolved. Federal law does not preempt stronger state protections, according to the National Academy for State Health Policy. State laws differ in how they handle payment disputes.
New York's state surprise billing law uses arbitration tied to provider charges, while California uses a payment standard approach. The federal No Surprises Act forbids arbitrators from considering provider charges during disputes—yet existing state laws with different standards remain in force because federal law permits them. States also retain independent regulatory authority to control what health care providers charge.
States can regulate provider charges and enforce balance billing protections on providers regardless of plan type—which means that even in a self-insured employer plan, a state can sometimes limit what a provider charges you after federal law's surprise billing protections fail. This is a narrower tool than an insurance law, but it exists.
How to Know If You're Protected and What to Do
Your protection depends on three things: your state, your plan type, and the type of service. Check all three before assuming you're covered. First, learn your plan type. Ask your employer or plan administrator: "Is my health plan fully insured or self-insured?" If self-insured, your plan is governed by federal ERISA law and federal surprise billing rules only.
State protections do not apply. If fully insured, state law protects you within your state's scope. Second, know what your state protects. If you live in one of the 22 states with ground ambulance protections and have a fully insured plan, you are protected for ambulance services—but only if your plan is fully insured. Other services may or may not be covered depending on your state's other surprise billing laws, which vary widely.
Third, understand that even state protections have limits. They apply to fully insured plans only, and only within the state's scope. If you're in a self-insured employer plan, contact your plan administrator about federal ERISA protections for surprise billing. If you receive a surprise bill despite these protections, you can file a complaint with your state insurance commissioner (if in a fully insured plan) or with the U.S. Department of Labor (if in a self-insured plan governed by ERISA).
Frequently Asked Questions
What if I received a surprise ambulance bill before I learned about these protections?
You can still act. If your plan is fully insured, file a complaint with your state insurance commissioner—include a copy of the bill and your appeal denial if you have one. If your plan is self-insured, file an appeal with your plan administrator and, if denied, contact the U.S. Department of Labor's Employee Benefits Security Administration.
How do I find out if my state has ground ambulance protections?
Contact your state insurance commissioner's office and ask directly. You can also call your health insurance plan's customer service and ask whether your plan covers ground ambulance surprise billing claims. Not all plans adopt state protections automatically, so confirm your plan's coverage even if your state has a law.