Most states follow the federal No Surprises Act—which took effect January 1, 2022—but some have added protections that go beyond it. Surprise billing laws vary most sharply around ambulances and mental health emergencies, not across the full medical landscape; 23 states protect ground ambulance patients, and a handful have expanded emergency mental health coverage beyond the federal baseline.
The federal law creates a foundation for all Americans. State laws either match it or add pieces—they cannot weaken it. If you have an employer plan, understanding whether you're covered by state or federal protections changes which legal standard applies to your bills.
Table of Contents
- What the Federal No Surprises Act Covers Everywhere
- Which States Added Ambulance and Mental Health Protections
- The Self-Funded Plan Loophole: Why Your Employer Plan May Not Have State Protection
- How to Find Your State's Rules and Challenge a Surprise Bill
- How Federal and State Laws Calculate What Providers Can Charge
- Frequently Asked Questions
What the Federal No Surprises Act Covers Everywhere
The No Surprises Act, enforced by the Centers for Medicare & Medicaid Services, protects you from surprise bills in three situations: emergency care at any hospital, non-emergency care at an in-network facility (even if your provider was out-of-network), and air ambulance services. You pay only what you'd owe at an in-network provider—your copay, coinsurance, or deductible—regardless of what an out-of-network provider bills.
The law does not cover ground ambulances, which remains the single largest gap in federal protection. Employers have also made No Surprises Act compliance their top 2026 priority for enforcement, meaning workers should see plans applying the law more consistently this year.
Which States Added Ambulance and Mental Health Protections
Twenty-three states now protect ground ambulance patients from surprise bills, but protections are not uniform. Colorado and Maryland protect private ambulances only. Florida and West Virginia limit protection to HMO plans. Illinois caps what you pay at the lesser of your copay or 10% of the ambulance bill.
These state additions fill a federal gap but do not apply uniformly to all insurance types in all states. Georgia and Washington have also expanded beyond the federal baseline to protect patients from surprise bills for mental health emergencies treated outside hospitals—a protection not guaranteed by federal law. If you live in a state with an ambulance or mental health protection, your state law applies instead of (or in addition to) the federal baseline.
The Self-Funded Plan Loophole: Why Your Employer Plan May Not Have State Protection
State surprise billing laws protect only fully-insured plans—the kind where your employer buys insurance from a company like UnitedHealth or Aetna. The federal No Surprises Act applies to both fully-insured and self-funded employer plans, which cover roughly 60% of insured Americans. If your employer self-funds its plan and pays claims directly, your state's ambulance or mental health laws do not protect you.
You have only federal protections—which do not cover ground ambulances. Ask your benefits administrator whether your plan is fully-insured or self-funded. If it's self-funded and you need an ambulance, the federal law alone applies: no state ambulance protection reaches you.
How to Find Your State's Rules and Challenge a Surprise Bill
The Centers for Medicare & Medicaid Services maintains a state-by-state summary of which state laws match or exceed federal protections. Search for your state by name to see whether your state covers ambulances, mental health emergencies, or other services. Your state's insurance commissioner's office can also answer whether a state law applies to your specific bill.
If you receive a surprise bill, contact your insurance plan first and cite the No Surprises Act or your state law by name. Ask the plan to apply in-network cost-sharing. If the plan refuses, file a complaint with your state insurance commissioner—penalties for violations range from $2,000–$5,000 under state law and up to $10,000 under federal law, and the Department of Labor is actively enforcing compliance in 2026. Include a copy of your bill, the plan's denial, and the legal statute you believe the provider or plan violated.
How Federal and State Laws Calculate What Providers Can Charge
The federal No Surprises Act uses a Qualified Payment Amount (QPA)—a plan's median contracted rate for the same service in the same geographic area, adjusted for inflation—to cap how much out-of-network providers can bill. State laws may use different formulas to set what providers can charge; a state's "median contract rate" may not follow the federal QPA methodology exactly. This technical difference affects how much a provider can legally bill you if they've lost the cost-sharing dispute.
Frequently Asked Questions
Does my state's ambulance law protect me if I have an employer self-funded plan?
No. State laws protect only fully-insured plans. Self-funded employer plans (which cover 60% of workers) fall under federal law only, which does not cover ground ambulances. Check with your benefits administrator whether your plan is self-funded.
What happens if an insurance plan ignores the No Surprises Act?
You can file a complaint with your state insurance commissioner. Federal violations carry penalties up to $10,000 per violation; state penalties range from $2,000–$5,000. The Department of Labor made No Surprises Act compliance its top 2026 enforcement priority.
How do I know if my state covers ground ambulances?
The Centers for Medicare & Medicaid Services maintains a state-by-state summary of which state laws exceed federal protections. Search for your state by name to see ambulance, mental health, or other state-specific coverage.