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Air Ambulances

Last Updated 5/27/2021

Issue: Air ambulances are used to quickly transport patients in life-threatening situations. Air ambulances are usually helicopters equipped with medical equipment and staffed by medical professionals just like traditional ground ambulances. According to the Association of Air Medical Services, more than 550,000 patients in the U.S. use air ambulance services every year. Air ambulance services have grown significantly in recent decades; in 2002 there were approximately 400 dedicated air ambulances, but by 2008 the number had more than doubled to over 800. 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 health care in rural settings. There are also concerns that such high growth in this industry may be an indicator of medically unnecessary use.

Costs for the average air ambulance trip run in the tens-of-thousands of dollars. These high costs can be attributed 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), was 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 the ACA as well as 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 while out-of-network air ambulance providers can leave 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 can lead to a practice known as balance billing where a provider bills the patient directly for any amount not covered by insurance. These bills can be tens-of-thousands of dollars.

In lieu of Congressional action on this issue, some states have looked for alternative ways to help protect consumers from extremely high bills. However, courts continue to find that state legislation in this area is preempted by the federal ADA.

This issue can also affect workers compensation 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. 

In December 2020, Congress passed the No Surprises Act, legislation that largely ends the practice of surprise out-of-network medical billing. Effective 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.  However, the arbitration guidelines in the bill may not be as effective in negotiating air ambulance rates as they are with health care providers. Ultimately, federal legislation is needed to provide state insurance regulators a workaround to the ADA.

Status: The FAA Reauthorization Act of 2018 included a provision to appoint an advisory committee on air ambulances and patient billing. The goal of the committee is 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 includes North Dakota Insurance Commissioner Jon Godfread. The committee began its work in January 2020. The NAIC continues to monitor developments of the advisory committee.

Committees Active on This Topic

Additional Resources

The Unfinished Business of Air Ambulance Bills
March 26, 2021, Health Affairs

High air ambulance charges concentrated in private equity-owned carriers
October 2020, The Brookings Institute

Out-of-Network Air Ambulance Bills: Prevalence, Magnitude, and Policy Solutions
June 2020, The Milbank Quarterly

AAPB Advisory Committee Updates
February 2020, U.S. Department of Transportation

U.S. DOT Announces Membership of the Air Ambulance and Patient Billing Advisory Committee
September 2019, U.S. Department of Transportation

Air Ambulance Billing
September 2019, NAIC Government Relations Issue Brief

Air Ambulances
August 2019, CIPR Regulator Insight Brief

Air Ambulance: Available Data Show Privately-Insured Patients are at Financial Risk
March 2019, GAO Report

Air Ambulance Regulation
January 2019, NAIC Government Relations Issue Brief

New Heights in Air Ambulance Costs
August 2017, CIPR Newsletter

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