Surprise bills and ambulance bills in North Dakota

State law adds protection for ground ambulance bills only. Air ambulance payment rules also exist.

Checked against official sources: October 30, 2026.

What North Dakota adds

State law

North Dakota ground ambulance balance billing law

Law: 2025 H.B. 1322; N.D. Cent. Code 23-27-08, 26.1-47-12

Which plans it covers

Health benefit plans from health care insurers subject to state insurance regulation (insurance companies, HMOs, hospital or medical service corporations). Self-funded employer plans are not state-regulated.

What it adds

State law adds protection for ground ambulance bills only. Air ambulance payment rules also exist.

Ground ambulance

The state protects you

A licensed basic or advanced life support ground ambulance service may not bill or collect from a covered person more than the deductible, coinsurance, copay or other cost sharing the person would owe to an in-network ambulance. The insurer must pay an out-of-network ground ambulance directly, at the lesser of 250% of Medicare or the billed charges.

Law: N.D. Cent. Code 23-27-08, 26.1-47-12

Where to complain in North Dakota

Attorney general: North Dakota Attorney General, Consumer Protection Division · 701-328-3404
Complaints about debt collectors and other businesses.
Health insurance: North Dakota Insurance Department · 701-328-2440
Problems with a state-regulated health plan, including ground ambulance balance bills.

Free tools, letters and checklist

Questions about medical bills in North Dakota

Am I protected from ground ambulance bills in North Dakota?

Nearby states

National rules that apply in every state

Nonprofit hospitals (federal rules)

Each nonprofit hospital must have a written financial assistance policy (FAP).

Law: 26 U.S.C. 501(r)(4); 26 CFR 1.501(r)-4

Before any ECA, the hospital must tell you about financial assistance and wait at least 120 days from the first bill sent after you left the hospital.

Law: 26 CFR 1.501(r)-6(c)(3)

You can apply for at least 240 days from the first bill sent after you left the hospital.

Law: 26 CFR 1.501(r)-1(b)(3)

If you apply during the application period, even with an incomplete application, the hospital and its collectors must stop starting or continuing ECAs until the hospital decides, or until you fail to send requested information within a reasonable time.

Law: 26 CFR 1.501(r)-6(c)(8)

Once you are found eligible, the hospital cannot charge you more than the amounts generally billed (AGB) to people with insurance for emergency or other medically necessary care, and must charge less than its full gross charges for other covered care.

Law: 26 U.S.C. 501(r)(5); 26 CFR 1.501(r)-5

Surprise bills (No Surprises Act)

With most private health plans (job-based plans, Marketplace and other individual plans), you are protected from surprise out-of-network bills for emergency care, for non-emergency care at an in-network hospital, hospital outpatient department or ambulatory surgical center, and for air ambulance services.

Law: 42 U.S.C. 300gg-111, 300gg-131, 300gg-132, 300gg-135

For protected services, you can't be charged more than your in-network cost-sharing (copay, coinsurance, deductible).

Law: 42 U.S.C. 300gg-131, 300gg-132

Ground ambulance services are generally not covered by these federal protections, unless a state law has different rules.

Law: CMS, Know your rights when using insurance

If you don't have insurance or won't use it, providers and facilities must usually give you a written good faith estimate.

Law: 42 U.S.C. 300gg-136; 45 CFR 149.610

If one provider's or facility's bill is at least $400 more than its good faith estimate, you can use the federal patient-provider dispute resolution process.

Law: 45 CFR 149.620(a)(2)(ii), (c)(1)

Credit reports

A collection account generally cannot be reported for more than 7 years.

Law: 15 U.S.C. 1681c(a)(4), (c)(1)

For a veteran's medical debt (care authorized by the VA from a non-VA provider, or a bill the VA charged in error), nationwide credit bureaus may not report it until 1 year after the care, and may not report it once it is fully paid or settled, when they know it is a veteran's medical debt.

Law: 15 U.S.C. 1681c(a)(7), (8); 15 U.S.C. 1681a

If a medical debt on your credit report is wrong, you can dispute it with the credit bureau for free.

Law: 15 U.S.C. 1681i(a)(1)

Debt collectors

A debt collector must give you validation information about the debt, including the amount and how to dispute it.

Law: 12 CFR 1006.34

If you dispute the debt in writing within the validation period, the collector must stop collecting the disputed amount until it sends you verification of the debt.

Law: 12 CFR 1006.38(c), (d)(2)

A debt collector must not sue or threaten to sue you on a time-barred debt, meaning a debt whose statute of limitations has run out.

Law: 12 CFR 1006.26(b)

Itemized bills and price lists

Your medical and billing records kept by a health care provider are part of your 'designated record set'.

Law: 45 CFR 164.501 (designated record set); 45 CFR 164.524(b)(2)

If Medicare paid for an item or service, you can ask the provider in writing for an itemized statement.

Law: 42 U.S.C. 1395b-7(b)

Every hospital must post online a machine-readable file of all its standard charges, and a consumer-friendly list of at least 300 shoppable services (or an online price estimator tool).

Law: 45 CFR 180.40, 180.50, 180.60

Medicaid and Medicare

If you qualify for Medicaid, it can pay for covered care you got up to 3 months before the month you applied, if you were eligible then.

Law: 42 U.S.C. 1396a(a)(34), 1396d(a); Pub. L. 119-21, sec. 71112 (July 4, 2025)

If you are in the Qualified Medicare Beneficiary (QMB) program, Medicare providers may not bill you for Medicare deductibles, coinsurance or copays for Medicare-covered care.

Law: 42 U.S.C. 1396a(n)(3)(B); CMS

If your health plan denies a claim

You must file an internal appeal within 180 days (6 months) of the notice that your claim was denied.

Law: 45 CFR 147.136(b); HealthCare.gov

After a final denial, you can ask for an external review by an independent reviewer within 4 months.

Law: 45 CFR 147.136(c), (d); HealthCare.gov

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