The coverage wall: 22 of 50

Each tile below is one state. Blue tiles are the states the Commonwealth Fund tracker counted with ground ambulance balance-billing protections as of Feb. 5, 2026. The gold tile is New Hampshire, the newest arrival. For the state-by-state roster and each statute's citation, go directly to the tracker itself; this wall shows the verified count, not a reconstructed list.

protection in effect (21 states)New Hampshire, effective Jan. 1, 2026no state protection (28 states)

How the gap got here

1. Jan. 1, 2022The federal No Surprises Act takes effect. Air ambulance is protected. Ground ambulance is expressly excluded, as the CMS No Surprises fact sheets confirm. The single most common source of surprise out-of-network bills is left to the states.
2. 2022 to 2025State legislatures fill the gap one statute at a time. No two laws are identical: each defines its own scope, its own plan types, and its own payment floor formula.
3. Jan. 1, 2026New Hampshire's prohibition takes effect (NH General Court, 2025 session law), covering emergency and non-emergency ground ambulance for state-regulated plans.
4. Feb. 5, 2026The Commonwealth Fund's state tracker counts 22 states with ground ambulance balance-billing protections.

The ERISA hole in every one of these laws

State insurance law cannot regulate self-funded employer plans governed by ERISA. That is not a drafting oversight in any of the 22 statutes, it is a federal preemption ceiling none of them can pierce. With roughly 60% of the commercially insured in ERISA self-funded plans, the majority of an operator's commercial book may see no change at all when a state law takes effect.

Same patient volume, same transports, two different legal regimes, split by plan funding status.

Every payment floor is a de facto rate

These laws pair the balance-billing ban with a minimum the insurer must pay for the out-of-network transport. Because the patient can no longer be billed for the difference, that statutory floor becomes the effective out-of-network rate for state-regulated business. The formulas are not standardized across the 22 states, so before booking expected yield, confirm which shape your state statute uses:

The operator to-do list

1. Split the payer book by funding status. Fully insured state-regulated, ERISA self-funded, and government business follow three different rule sets. Nothing downstream is accurate until this segmentation exists.
2. Map your footprint against the tracker. Check every state you transport in against the Commonwealth Fund 22-state tracker (Feb. 5, 2026), then pull the actual statute for scope, plan types, and effective date.
3. Re-model expected out-of-network yield. In protected states, the statutory floor is your rate for state-regulated claims. New Hampshire operations need a Jan. 1, 2026 date-of-service split in the model.
4. Patch billing-system edits. Suppress patient balance statements on protected claims, keyed to plan funding status and date of service, not just payer name.
5. Rewrite patient-facing statements and scripts. A balance bill sent on a protected claim in a prohibition state is a compliance event, not a collections tactic.
6. Handle ERISA claims as their own workstream. The state floor does not apply, so out-of-network strategy, appeals, and patient communication for self-funded claims must be documented plan by plan.
7. Assume the count keeps moving. The tracker reached 22 in the Feb. 5, 2026 snapshot. Build a legislative-watch step into your quarterly payer-rules review rather than treating 22 as final.