Health Insurance and Managed Care (B) Committee
Wednesday, August 13, 2025
10:45 AM CDT
Minneapolis Convention Center—101—Level 1
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Air Ambulances
Background
Last Updated: 10/1/2025
Issue: Air ambulances are used to quickly transport patients in life-threatening situations. Air ambulances are helicopters or fixed-wing aircraft equipped with medical equipment and staffed by medical professionals just like traditional ground ambulances. According to the , more than 550,000 patients in the U.S. use air ambulance services every year. Air ambulance services have grown significantly in recent decades. Specifically, the number of Air Ambulance Services in the U.S. grew at an average annual rate of 6.9% between 2019 and 2024, reaching 701 businesses in 2024. More broadly, the overall U.S. ambulance services market was valued at approximately $19.15 billion in 2023 and is expected to grow significantly, with projections estimating it will reach about $52.78 billion by 2033, representing a over the 2024 to 2033 period. Possible reasons for the growth of this industry include an aging population, a decline in the number of emergency departments in existing hospitals, and changes in the delivery of healthcare in rural settings. There are that such high growth in this industry may be an indicator of medically unnecessary use.
It's estimated that the median cost of single transport by air ambulance is between . These high costs can be attributed in part to maintenance of expensive equipment as well as the need to staff specialized medical personnel around-the-clock.
Background: The Airline Deregulation Act of 1978 (ADA), intended to encourage competition in the airline industry, prohibits states from regulating the prices air carriers charge. Therefore, state laws passed to regulate the costs of air ambulance services are preempted by the ADA. In contrast, traditional ground ambulance services are regulated under any applicable state laws.
Over the past decade, many states have reported issues with air ambulance providers not affiliated with any hospital or insurance carrier. This leaves patients in some areas with no in-network choices for life-saving care. Prior to the No Surprises Act (see below), this left some patients with enormous bills. Additionally, although Medicare, Medicaid, and most private insurers provide some coverage for air ambulance services, reimbursement rates are often far lower than what air ambulance providers bill. This formerly led to a practice known as balance billing in which a provider bills the patient directly for any amount not covered by insurance.
This issue can also affect insurance and auto insurance as air ambulance flights can often be required in workplace or auto accident situations which can then lead to billing confusion.
State action to adopt legislation to help protect consumers from extremely high bills has largely been preempted by the federal ADA.
In December 2020, Congress passed the legislation that largely ends the practice of surprise out-of-network medical billing. The No Surprises Act went into effect January 1, 2022. The law applies to air ambulance operators as well as out-of-network health providers and facilities providing emergency and non-emergency care. The No Surprises Act introduces several key consumer protections related to air ambulance services. Most importantly, the law prohibits balance billing by providers of air ambulance services. To promote transparency, the Act also requires providers of air ambulance services to submit data to the Department of Health and Human Services, including , details on air ambulance bases and aircraft, the number and nature of air ambulance transports, payor data, and data on claims denials. Further, the Act established an independent dispute resolution (IDR) process to help resolve payment disputes between air ambulance providers and insurers when agreement cannot be reached. Notably, in 2023, air ambulance organizations prevailed in approximately resolved through this IDR process.
Actions
Status: The FAA Reauthorization Act of 2018 included a provision to appoint an on air ambulances and patient billing. The goal of the committee was to make recommendations to improve the disclosure of charges and fees for air medical services, better inform consumers of insurance options for such services, and protect consumers from balance billing. The U.S. Department of Transportation announced the membership in September 2019 which included North Dakota Insurance Commissioner Jon Godfread. The committee issued a that includes recommendations on disclosures, best practices for contract and network negotiations, and areas for future data collection and study. The committee also recommended that the U.S. Congress should amend the ADA to avoid preemption of state laws in a few key areas relating to air ambulances. The ²»Á¼Ñо¿Ëù¹Ù·½ continues to monitor any action on the committee’s recommendations.
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